Provider Demographics
NPI:1902215577
Name:CENTINELA MEDICAL GROUP
Entity Type:Organization
Organization Name:CENTINELA MEDICAL GROUP
Other - Org Name:PARKLANE MEDICAL GROUP INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:CHIKE
Authorized Official - Last Name:IFEORAH
Authorized Official - Suffix:
Authorized Official - Credentials:LAC,QME
Authorized Official - Phone:310-367-3107
Mailing Address - Street 1:4405 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90037-2731
Mailing Address - Country:US
Mailing Address - Phone:323-231-0965
Mailing Address - Fax:323-231-6512
Practice Address - Street 1:4405 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037-2731
Practice Address - Country:US
Practice Address - Phone:323-231-0965
Practice Address - Fax:323-231-6512
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PARKLANE MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-08-08
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAFNP31076208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW11686Medicare PIN