Provider Demographics
NPI:1659032787
Name:CENTENO, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CENTENO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 W ORANGE GROVE AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91768-2032
Mailing Address - Country:US
Mailing Address - Phone:909-236-6399
Mailing Address - Fax:
Practice Address - Street 1:18623 GALE AVE STE 154
Practice Address - Street 2:
Practice Address - City:CITY OF INDUSTRY
Practice Address - State:CA
Practice Address - Zip Code:91748-1342
Practice Address - Country:US
Practice Address - Phone:626-839-0300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-30
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist