Healthcare Provider Details

I. General information

NPI: 1891003497
Provider Name (Legal Business Name): CENTENNIAL MEDICAL GROUP WEST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2010
Last Update Date: 09/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 NW MERCY DR SUITE 345
ROSEBURG OR
97471-2348
US

IV. Provider business mailing address

2801 NW MERCY DR SUITE 340
ROSEBURG OR
97471-2348
US

V. Phone/Fax

Practice location:
  • Phone: 541-677-2494
  • Fax: 541-677-2294
Mailing address:
  • Phone: 541-677-2494
  • Fax: 541-677-2294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberMD15315
License Number StateOR

VIII. Authorized Official

Name: RAHUL AGARWAL
Title or Position: PRESIDENT
Credential:
Phone: 541-677-2494