=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013807361
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTENNIAL MEDICAL GROUP LLP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2025
-----------------------------------------------------
Last Update Date | 07/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4050 E RUSSELL RD STE 100
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89120-3810
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-893-1203
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4454 N DECATUR BLVD
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89130-5286
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-893-1203
-----------------------------------------------------
Fax | 702-893-1301
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF BILLING
-----------------------------------------------------
Name | KELLIE MERRILL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 702-839-1203
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------