Provider Demographics
NPI:1790401388
Name:CENTER STREET
Entity Type:Organization
Organization Name:CENTER STREET
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NILAH
Authorized Official - Middle Name:EMAGE ASY JAMIE
Authorized Official - Last Name:QUINONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-316-7585
Mailing Address - Street 1:2739 W RANCHO DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85017-2645
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5949 W NORTHERN AVE STE 201
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-7829
Practice Address - Country:US
Practice Address - Phone:323-233-1675
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-14
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No251S00000XAgenciesCommunity/Behavioral Health