Healthcare Provider Details

I. General information

NPI: 1649612128
Provider Name (Legal Business Name): PHOENIX MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2013
Last Update Date: 07/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7851 MISSION CENTER CT SUITE 205
SAN DIEGO CA
92108-1325
US

IV. Provider business mailing address

3576 ARLINGTON AVE SUITE 100
RIVERSIDE CA
92506-3943
US

V. Phone/Fax

Practice location:
  • Phone: 909-937-3400
  • Fax: 909-937-3411
Mailing address:
  • Phone: 951-687-6600
  • Fax: 951-687-6601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. BRENT PRATLEY
Title or Position: ORTHOPEDIC
Credential: MD
Phone: 951-687-6600