Healthcare Provider Details

I. General information

NPI: 1568515492
Provider Name (Legal Business Name): CENTENNIAL MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 09/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

232 W 4TH ST
LOVELAND CO
80537-5525
US

IV. Provider business mailing address

232 W 4TH ST
LOVELAND CO
80537-5525
US

V. Phone/Fax

Practice location:
  • Phone: 970-667-3565
  • Fax: 970-667-2343
Mailing address:
  • Phone: 970-667-3565
  • Fax: 970-667-2343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number15838
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number22781
License Number StateCO

VIII. Authorized Official

Name: JENNY RILEY
Title or Position: OFFICE MANAGER
Credential:
Phone: 970-667-3565