Healthcare Provider Details

I. General information

NPI: 1023736022
Provider Name (Legal Business Name): DONNA CENTENO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2022
Last Update Date: 11/22/2022
Certification Date: 11/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 TERRACINA BLVD STE 102
REDLANDS CA
92373-4865
US

IV. Provider business mailing address

PO BOX 10069
SAN BERNARDINO CA
92423-0069
US

V. Phone/Fax

Practice location:
  • Phone: 909-792-2605
  • Fax:
Mailing address:
  • Phone: 909-335-4188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number61974
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: