Basic Information
| Provider Information | |||||||||
| NPI: | 1972662187 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTENNIAL FAMILY HEALTH CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 319 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ORDWAY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810631302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192673503 | ||||||||
| FaxNumber: | 7192674153 | ||||||||
| Practice Location | |||||||||
| Address1: | 319 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ORDWAY | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810631302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7192673503 | ||||||||
| FaxNumber: | 7192674153 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | TOMKY | ||||||||
| AuthorizedOfficialFirstName: | KAREN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7192673503 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | NP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 305R00000X | CO | Y | Managed Care Organizations | Preferred Provider Organization |
ID Information
| ID | Type | State | Issuer | Description | 21001880 | 05 | CO | MEDICAID |