Healthcare Provider Details

I. General information

NPI: 1669747150
Provider Name (Legal Business Name): PHOENIX MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2012
Last Update Date: 03/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4355 E AIRPORT DR SUITE 100
ONTARIO CA
91761-7812
US

IV. Provider business mailing address

4355 E AIRPORT DR SUITE 100
ONTARIO CA
91761-7812
US

V. Phone/Fax

Practice location:
  • Phone: 818-701-1800
  • Fax: 818-885-1171
Mailing address:
  • Phone: 818-701-1800
  • Fax: 818-885-1171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: MS. WENDY MORLEY
Title or Position: BILLER
Credential:
Phone: 818-701-1800