Healthcare Provider Details

I. General information

NPI: 1528962925
Provider Name (Legal Business Name): SAGE MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20935 VANOWEN ST STE 203
CANOGA PARK CA
91303-3806
US

IV. Provider business mailing address

20935 VANOWEN ST STE 203
CANOGA PARK CA
91303-3806
US

V. Phone/Fax

Practice location:
  • Phone: 747-325-4293
  • Fax: 747-240-4013
Mailing address:
  • Phone: 747-325-4293
  • Fax: 747-240-4013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: IVY BELLEZO
Title or Position: OFFICE MANAGER
Credential:
Phone: 747-213-7483