Provider Demographics
NPI:1639137938
Name:CENTRELAKE MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:CENTRELAKE MEDICAL GROUP, INC.
Other - Org Name:CENTRELAKE IMAGING & ONCOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:AMAR
Authorized Official - Middle Name:A
Authorized Official - Last Name:LAPSI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-212-6206
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:909-635-0411
Mailing Address - Fax:909-635-0441
Practice Address - Street 1:3115 E GUASTI RD
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91761-7853
Practice Address - Country:US
Practice Address - Phone:909-635-0411
Practice Address - Fax:909-635-0441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2085R0202X
CAFNP34299261QM1200X, 261QX0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)
No261QX0203XAmbulatory Health Care FacilitiesClinic/CenterOncology, RadiationGroup - Single Specialty