Basic Information
| Provider Information | |||||||||
| NPI: | 1659032787 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CENTENO | ||||||||
| FirstName: | NICOLE | ||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1800 W ORANGE GROVE AVE APT 1 | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917682032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9092366399 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 18623 GALE AVE STE 154 | ||||||||
| Address2: | |||||||||
| City: | CITY OF INDUSTRY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917481342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268390300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2021 | ||||||||
| LastUpdateDate: | 12/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | Other Service Providers | Specialist |
No ID Information.