Basic Information
| Provider Information | |||||||||
| NPI: | 1043654676 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTINELA MEDICAL GROUP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PARKLANE MEDICAL GROUP INC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12900 AVALON BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900612734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105385222 | ||||||||
| FaxNumber: | 3105327888 | ||||||||
| Practice Location | |||||||||
| Address1: | 12900 AVALON BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900612734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105385222 | ||||||||
| FaxNumber: | 3105327888 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2013 | ||||||||
| LastUpdateDate: | 04/25/2013 | ||||||||
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| AuthorizedOfficialLastName: | IFEORAH | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
| AuthorizedOfficialMiddleName: | CHIKE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3103673107 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PARKLANE MEDICAL GROUP INC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | LAC, QME | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | FNP 31076 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.