Provider Demographics
NPI:1992707988
Name:CENTANNI, CARMEN J
Entity type:Individual
Prefix:
First Name:CARMEN
Middle Name:J
Last Name:CENTANNI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:CARMEN
Other - Middle Name:J
Other - Last Name:CENTANNI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:3681 SOUTH GREEN RD.
Mailing Address - Street 2:SUITE #206
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122
Mailing Address - Country:US
Mailing Address - Phone:216-595-3560
Mailing Address - Fax:216-595-3560
Practice Address - Street 1:3681 SOUTH GREEN RD.
Practice Address - Street 2:SUITE #206
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122
Practice Address - Country:US
Practice Address - Phone:216-595-3560
Practice Address - Fax:216-595-3560
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH711111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000116505OtherANTHEM BCBS
000000116505OtherANTHEM BC/BS
T47039Medicare UPIN
OH000000116505OtherANTHEM BCBS