NPIMap

Organization Active NPI

Centrelake Medical Group, Inc.

  • Diagnostic Radiology Physician
  • Chino, CA
National Provider Identifier
1629636006
Registry record updated May 24, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Diagnostic Radiology PhysicianTaxonomy code 2085R0202X
Legal business name
CENTRELAKE MEDICAL GROUP, INC.
Practice address
5562 Philadelphia St Ste 100
Chino, CA 91710-2482
Phone
(909) 242-7300
Fax
(909) 784-3760
NPI assigned
May 31, 2019
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 24, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Tania Ceja
Title
Manager
Phone
(909) 242-7300

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Diagnostic Radiology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 2085R0202X Primary

Addresses

Primary practice location

5562 Philadelphia St Ste 100
Chino, CA 91710-2482

Mailing address

3115 E Guasti Rd
Ontario, CA 91761-7853
Phone (909) 242-7300

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20230517001362 CA Part B Supplier - Independent Diagnostic Testing Facility (Idtf) 1658471123 Practice locations: Chino, CA

Other NPIs with the same Medicare PAC ID 10

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Centrelake Imaging Oncolog10 organizations share this tax ID, including this one

Other organizations with this tax ID 9

Organizations that report the same tax identification number in the National Provider Directory.

Locations

5562 Philadelphia St
Ste 100
Chino, CA 91710
Phone (909) 242-7300

Practitioners & affiliated clinicians

Practitioners 8

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1559260800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1621814400000",
    "number": "1629636006",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3115 E GUASTI RD",
            "city": "ONTARIO",
            "state": "CA",
            "postal_code": "917617853",
            "telephone_number": "909-242-7300",
            "fax_number": "909-784-3760"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5562 PHILADELPHIA ST STE 100",
            "city": "CHINO",
            "state": "CA",
            "postal_code": "917102482",
            "telephone_number": "909-242-7300",
            "fax_number": "909-784-3760"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTRELAKE MEDICAL GROUP, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-05-31",
        "last_updated": "2021-05-24",
        "certification_date": "2021-05-24",
        "status": "A",
        "authorized_official_last_name": "CEJA",
        "authorized_official_first_name": "TANIA",
        "authorized_official_title_or_position": "MANAGER",
        "authorized_official_telephone_number": "909-242-7300"
    },
    "taxonomies": [
        {
            "code": "2085R0202X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Radiology, Diagnostic Radiology",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Chino, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 24, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.