Healthcare Provider Details

I. General information

NPI: 1639137938
Provider Name (Legal Business Name): CENTRELAKE MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3115 E GUASTI RD
ONTARIO CA
91761-7853
US

IV. Provider business mailing address

3115 E GUASTI RD
ONTARIO CA
91761-7853
US

V. Phone/Fax

Practice location:
  • Phone: 909-635-0411
  • Fax: 909-635-0441
Mailing address:
  • Phone: 909-635-0411
  • Fax: 909-635-0441

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QM1200X
TaxonomyMagnetic Resonance Imaging (MRI) Clinic/Center
License NumberFNP34299
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code261QX0203X
TaxonomyRadiation Oncology Clinic/Center
License NumberFNP34299
License Number StateCA

VIII. Authorized Official

Name: MR. AMAR A LAPSI
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 909-212-6206