Healthcare Provider Details

I. General information

NPI: 1336328244
Provider Name (Legal Business Name): PRIME HEALTHCARE CENTINELA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2007
Last Update Date: 11/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 E HARDY ST
INGLEWOOD CA
90301-4011
US

IV. Provider business mailing address

3300 E GUASTI RD 3RD FLOOR
ONTARIO CA
91761-8655
US

V. Phone/Fax

Practice location:
  • Phone: 310-680-1488
  • Fax: 909-464-8887
Mailing address:
  • Phone: 909-235-4307
  • Fax: 909-235-4316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number930000027
License Number StateCA

VIII. Authorized Official

Name: CHRISTOPHER DOAN
Title or Position: CHIEF COMPLIANCE COUNSEL
Credential:
Phone: 909-235-4307