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General NPI Number Information
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NPI Number | 1568515492
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Entity Type | Organization
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Legal Business Name | CENTENNIAL MEDICAL CLINIC
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Dates
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Enumeration Date | 01/22/2007
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Last Update Date | 09/26/2007
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Provider Practice Location Address
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Address Line | 232 W 4TH ST
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City | LOVELAND
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State | CO
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Zip | 80537-5525
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Country | US
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Telephone | 970-667-3565
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Fax | 970-667-2343
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Provider Business Mailing Address
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Address Line | 232 W 4TH ST
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City | LOVELAND
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State | CO
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Zip | 80537-5525
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Country | US
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Telephone | 970-667-3565
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Fax | 970-667-2343
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | JENNY RILEY
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Credential |
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Telephone | 970-667-3565
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 22781
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License Number State | CO
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 15838
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License Number State | CO
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