Provider Demographics
NPI:1629425350
Name:CENTRIA
Entity Type:Organization
Organization Name:CENTRIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ABA
Authorized Official - Prefix:
Authorized Official - First Name:JALONDA
Authorized Official - Middle Name:
Authorized Official - Last Name:DUKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-893-1877
Mailing Address - Street 1:3051 COURTZ ISLE APT 5
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-4207
Mailing Address - Country:US
Mailing Address - Phone:810-893-1877
Mailing Address - Fax:
Practice Address - Street 1:3051 COURTZ ISLE APT 5
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-4207
Practice Address - Country:US
Practice Address - Phone:810-893-1877
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-23
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI242700000XOtherTECHNICIAN-OTHER