Provider Demographics
NPI:1689800377
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:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:AMAR
Authorized Official - Middle Name:
Authorized Official - Last Name:LAPSI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-331-6866
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 1:1555 N ORANGE GROVE AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3811
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:2009-06-08
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty