Healthcare Provider Details

I. General information

NPI: 1851821680
Provider Name (Legal Business Name): PHYSICIAN HEALTH COLLABORATIVE CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11497 BARTLETT AVE STE B1
ADELANTO CA
92301-1901
US

IV. Provider business mailing address

11497 BARTLETT AVE STE B1
ADELANTO CA
92301-1901
US

V. Phone/Fax

Practice location:
  • Phone: 760-246-6600
  • Fax: 760-955-8558
Mailing address:
  • Phone: 760-246-6600
  • Fax: 760-955-8558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA87666
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG57910
License Number StateCA

VIII. Authorized Official

Name: STUART LEVINE
Title or Position: SOLE SHAREHOLDER
Credential: MD
Phone: 760-955-9555