Healthcare Provider Details

I. General information

NPI: 1205172848
Provider Name (Legal Business Name): JEFFREY PAUL CENTENO RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/01/2013
Last Update Date: 01/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7484 LARSEN BAY ST
EASTVALE CA
92880-9197
US

IV. Provider business mailing address

7484 LARSEN BAY ST
EASTVALE CA
92880-9197
US

V. Phone/Fax

Practice location:
  • Phone: 714-865-8418
  • Fax:
Mailing address:
  • Phone: 714-865-8418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number650182
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: