Healthcare Provider Details

I. General information

NPI: 1629636006
Provider Name (Legal Business Name): CENTRELAKE MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2019
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5562 PHILADELPHIA ST STE 100
CHINO CA
91710-2482
US

IV. Provider business mailing address

3115 E GUASTI RD
ONTARIO CA
91761-7853
US

V. Phone/Fax

Practice location:
  • Phone: 909-242-7300
  • Fax: 909-784-3760
Mailing address:
  • Phone: 909-242-7300
  • Fax: 909-784-3760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: TANIA CEJA
Title or Position: MANAGER
Credential:
Phone: 909-242-7300