Provider Demographics
NPI:1760721112
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: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:909-242-7300
Mailing Address - Fax:909-784-3760
Practice Address - Street 1:1700 W WEST COVINA PKWY
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-2706
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:2013-02-05
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAFNP34299261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ05166ZMedicare PIN