Basic Information
| Provider Information | |||||||||
| NPI: | 1356401160 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTOC MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27401 LOS ALTOS | ||||||||
| Address2: | SUITE 180 | ||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926916316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495829624 | ||||||||
| FaxNumber: | 9495829626 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 W LA VETA AVE | ||||||||
| Address2: | SUITE 604 | ||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928684213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146334020 | ||||||||
| FaxNumber: | 7146334846 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 08/20/2007 | ||||||||
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| AuthorizedOfficialLastName: | BARRETTO | ||||||||
| AuthorizedOfficialFirstName: | ROBERTO | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7146334020 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | GR0103190 | 05 | CA | MEDICAID |