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General NPI Number Information
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NPI Number | 1043654676
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Entity Type | Organization
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Legal Business Name | CENTINELA MEDICAL GROUP
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Dates
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Enumeration Date | 04/25/2013
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Last Update Date | 04/25/2013
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Provider Practice Location Address
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Address Line | 12900 AVALON BLVD
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City | LOS ANGELES
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State | CA
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Zip | 90061-2734
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Country | US
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Telephone | 310-538-5222
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Fax | 310-532-7888
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Provider Business Mailing Address
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Address Line | 12900 AVALON BLVD
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City | LOS ANGELES
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State | CA
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Zip | 90061-2734
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Country | US
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Telephone | 310-538-5222
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Fax | 310-532-7888
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. GEORGE CHIKE IFEORAH
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Credential | LAC, QME
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Telephone | 310-367-3107
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | FNP 31076
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License Number State | CA
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