MEDICARE: CENTINELA MEDICAL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	FNP 31076	CA

General Provider Information

NPI Number	:	1043654676
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTINELA MEDICAL GROUP

Provider Business Mailing Address
First Line	:	12900 AVALON BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90061-2734
Country	:	US
Telephone Number	:	310-538-5222
Fax Number	:	310-532-7888

Provider Business Practice Location Address
First Line	:	12900 AVALON BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90061-2734
Country	:	US
Telephone Number	:	310-538-5222
Fax Number	:	310-532-7888

Authorized Official
Title or Position	:	DIRECTOR
Name	:	DR. GEORGE CHIKE IFEORAH
Credential	:	LAC, QME
Telephone Number	:	310-367-3107

Provider Enumeration Date	:	04/25/2013
Last Update Date	:	04/25/2013

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