Basic Information
| Provider Information | |||||||||
| NPI: | 1134335128 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PARKLANE MEDICAL GROUP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CENTINELA MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12900 SOUTH AVALON BL. | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105385222 | ||||||||
| FaxNumber: | 3105327888 | ||||||||
| Practice Location | |||||||||
| Address1: | 12900 SOUTH AVALON BL. | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3105385222 | ||||||||
| FaxNumber: | 3105327888 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | IFEORAH | ||||||||
| AuthorizedOfficialFirstName: | GEORGE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3105385222 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LAC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0102062 | 05 | CA | MEDICAID |