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General NPI Number Information
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NPI Number | 1750980967
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Entity Type | Organization
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Legal Business Name | CENTRELAKE MEDICAL GROUP INC
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Dates
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Enumeration Date | 10/19/2020
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Last Update Date | 10/19/2020
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Provider Practice Location Address
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Address Line | 430 W STETSON AVE
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City | HEMET
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State | CA
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Zip | 92543-7328
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Country | US
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Telephone | 909-242-7300
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Fax | 909-784-3760
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Provider Business Mailing Address
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Address Line | 3115 E GUASTI RD
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City | ONTARIO
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State | CA
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Zip | 91761-7853
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Country | US
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Telephone | 909-242-7300
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Fax | 909-784-3760
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Authorized Official
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Title or Position | LEAD SITE MANAGER
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Name | TANIA CEJA
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Credential |
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Telephone | 909-242-7300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number |
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License Number State |
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