NPIMap

Organization Active NPI

Centrelake Medical Group Inc

  • Diagnostic Radiology Physician
  • Hemet, CA
National Provider Identifier
1750980967
Registry record updated Oct 19, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Diagnostic Radiology PhysicianTaxonomy code 2085R0202X
Legal business name
CENTRELAKE MEDICAL GROUP INC
Practice address
430 W Stetson Ave
Hemet, CA 92543-7328
Phone
(909) 242-7300
Fax
(909) 784-3760
NPI assigned
Oct 19, 2020
Organization subpart
Yes
Parent organization
CENTRELAKE MEDICAL GROUP INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Oct 19, 2020

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

Authorized official

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

Specialties & licenses 1

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

Addresses

Primary practice location

430 W Stetson Ave
Hemet, CA 92543-7328

Mailing address

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

Other identifiers 2

IdentifierTypeStateIssuer
NAOtherRADIOLOGY
XXXMedicaidCA

Other names 1

  • Centrelake Imaging & Oncology Doing business as

Electronic endpoints 1

TypeEndpointUseAffiliation
Other URL centrelakeimaging.com

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20210324003086 CA Part B Supplier - Independent Diagnostic Testing Facility (Idtf) 1658471123 Practice locations: Hemet, 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
Part of
Centrelake Imaging Oncolog

Other organizations with this tax ID 9

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

Locations

430 W Stetson Ave
Ste A
Hemet, CA 92543

3115 E Guasti Rd
Ontario, CA 91761
Phone (626) 331-6866

Practitioners & affiliated clinicians

Practitioners 9

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": "1603065600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1603065600000",
    "number": "1750980967",
    "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": "430 W STETSON AVE",
            "city": "HEMET",
            "state": "CA",
            "postal_code": "925437328",
            "telephone_number": "909-242-7300",
            "fax_number": "909-784-3760"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CENTRELAKE MEDICAL GROUP INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "CENTRELAKE MEDICAL GROUP INC",
        "enumeration_date": "2020-10-19",
        "last_updated": "2020-10-19",
        "certification_date": "2020-10-19",
        "status": "A",
        "authorized_official_last_name": "CEJA",
        "authorized_official_first_name": "TANIA",
        "authorized_official_title_or_position": "LEAD SITE 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": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RADIOLOGY",
            "identifier": "NA",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "XXX",
            "state": "CA"
        }
    ],
    "endpoints": [
        {
            "endpointType": "OTHERS",
            "endpointTypeDescription": "Other URL",
            "endpoint": "centrelakeimaging.com",
            "affiliation": "N",
            "address_1": "430 W Stetson Ave",
            "city": "Hemet",
            "state": "CA",
            "country_code": "US",
            "postal_code": "925437328",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": [
        {
            "organization_name": "Centrelake Imaging & Oncology",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Hemet, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 19, 2020; 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.