Provider Demographics
NPI:1063710192
Name:CENTENNIAL MEDICAL GROUP WEST, LLC
Entity type:Organization
Organization Name:CENTENNIAL MEDICAL GROUP WEST, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAHUL
Authorized Official - Middle Name:
Authorized Official - Last Name:AGARWAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-677-2494
Mailing Address - Street 1:2801 NW MERCY DR STE 340
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-2348
Mailing Address - Country:US
Mailing Address - Phone:541-677-2494
Mailing Address - Fax:541-677-2294
Practice Address - Street 1:2700 NW STEWART PKWY
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-1281
Practice Address - Country:US
Practice Address - Phone:541-677-2494
Practice Address - Fax:541-677-2294
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CENTENNIAL MEDICAL GROUP, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-15
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty