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NPI Code Detail

MEDICARE: TRIBALIGHTS TT LLC

MEDICARE: TRIBALIGHTS TT LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1251S00000XCommunity/Behavioral Health Agency

General Provider Information

NPI Number : 1568241669
Entity Type Code : Organization
Provider Name (Legal Business Name) : TRIBALIGHTS TT LLC
Provider Business Mailing Address
First Line : 20548 VENTURA BLVD # 10-407
Second Line :
City : WOODLAND HILLS
State : CA
Zip : 91364-6225
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1316 APACHE AVE
Second Line :
City : SANTA FE
State : NM
Zip : 87505-3212
Country : US
Telephone Number : 310-721-4398
Fax Number :
Authorized Official
Title or Position : CO-FOUNDER & COO
Name : PHOENIX GERMANO
Credential :
Telephone Number : 310-721-4398
Provider Enumeration Date : 09/27/2023
Last Update Date : 11/22/2024

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