Healthcare Provider Details

I. General information

NPI: 1932656337
Provider Name (Legal Business Name): PHILNLN, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2016
Last Update Date: 09/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7619 MORRO RD
ATASCADERO CA
93422-4433
US

IV. Provider business mailing address

10 SANTA ROSA ST STE 201
SAN LUIS OBISPO CA
93405-5825
US

V. Phone/Fax

Practice location:
  • Phone: 805-461-9192
  • Fax: 805-461-5802
Mailing address:
  • Phone: 805-786-4878
  • Fax: 805-597-8356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA44775
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberA47889
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA47889
License Number StateCA

VIII. Authorized Official

Name: DR. PHILIP JOSEPH CITEK
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 805-909-0612