Provider Demographics
NPI:1790494128
Name:CENTRELAKE MEDICAL GROUP INC
Entity Type:Organization
Organization Name:CENTRELAKE MEDICAL GROUP INC
Other - Org Name:WESTWOOD OPEN MRI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CENTER OPERATIONS DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NISHANT
Authorized Official - Middle Name:
Authorized Official - Last Name:NIROOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-242-7300
Mailing Address - Street 1:10921 WILSHIRE BLVD
Mailing Address - Street 2:MEZZANINE LEVEL
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-3906
Mailing Address - Country:US
Mailing Address - Phone:310-208-3100
Mailing Address - Fax:310-208-3101
Practice Address - Street 1:10921 WILSHIRE BLVD
Practice Address - Street 2:MEZZANINE LEVEL
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90024-3906
Practice Address - Country:US
Practice Address - Phone:310-208-3100
Practice Address - Fax:310-208-3101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1200XAmbulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)Group - Single Specialty