Healthcare Provider Details

I. General information

NPI: 1497536791
Provider Name (Legal Business Name): PHYLENE RIRIE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2023
Last Update Date: 10/18/2023
Certification Date: 10/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9671 DEER VALLEY RD
BRENTWOOD CA
94513-4907
US

IV. Provider business mailing address

5129 LONE TREE WAY
ANTIOCH CA
94531-8484
US

V. Phone/Fax

Practice location:
  • Phone: 925-383-4810
  • Fax:
Mailing address:
  • Phone: 925-383-4810
  • Fax: 925-226-0812

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: