Provider Demographics
NPI:1629636006
Name:CENTRELAKE MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:CENTRELAKE MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TANIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CEJA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-242-7300
Mailing Address - Street 1:3115 E GUASTI RD
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-7853
Mailing Address - Country:US
Mailing Address - Phone:909-242-7300
Mailing Address - Fax:909-784-3760
Practice Address - Street 1:5562 PHILADELPHIA ST STE 100
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-2482
Practice Address - Country:US
Practice Address - Phone:909-242-7300
Practice Address - Fax:909-784-3760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-31
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty