Provider Demographics
NPI:1740170091
Name:CENTENNIAL MEDICAL GROUP LLP
Entity type:Organization
Organization Name:CENTENNIAL MEDICAL GROUP LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BILLING
Authorized Official - Prefix:
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MERRILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-839-1203
Mailing Address - Street 1:4454 N DECATUR BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89130-5286
Mailing Address - Country:US
Mailing Address - Phone:702-893-1203
Mailing Address - Fax:702-893-1301
Practice Address - Street 1:7800 CONSTITUTION AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-7552
Practice Address - Country:US
Practice Address - Phone:505-296-6565
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-07-08
Last Update Date:2025-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies