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	FNP31076	CA

General Provider Information

NPI Number	:	1902215577
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTINELA MEDICAL GROUP

Provider Business Mailing Address
First Line	:	4405 S MAIN ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90037-2731
Country	:	US
Telephone Number	:	323-231-0965
Fax Number	:	323-231-6512

Provider Business Practice Location Address
First Line	:	4405 S MAIN ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90037-2731
Country	:	US
Telephone Number	:	323-231-0965
Fax Number	:	323-231-6512

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

Provider Enumeration Date	:	08/08/2014
Last Update Date	:	08/08/2014

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