Provider Demographics
NPI:1710348818
Name:CENTENNIAL FAMILY CARE PC
Entity Type:Organization
Organization Name:CENTENNIAL FAMILY CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:GENEVIEVE
Authorized Official - Last Name:POTURALSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:303-471-2466
Mailing Address - Street 1:7261 S BROADWAY STE 101A
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80122-8018
Mailing Address - Country:US
Mailing Address - Phone:303-471-2466
Mailing Address - Fax:303-471-6066
Practice Address - Street 1:7261 S BROADWAY STE 101A
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80122-8018
Practice Address - Country:US
Practice Address - Phone:303-471-2466
Practice Address - Fax:303-471-6066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0033806207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COG21848Medicare UPIN