Healthcare Provider Details

I. General information

NPI: 1366023301
Provider Name (Legal Business Name): PHANTOM HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2021
Last Update Date: 03/23/2023
Certification Date: 03/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14545 FRIAR ST STE 377
VAN NUYS CA
91411-2397
US

IV. Provider business mailing address

14545 FRIAR ST STE 377
VAN NUYS CA
91411-2397
US

V. Phone/Fax

Practice location:
  • Phone: 970-550-0000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number
License Number State

VIII. Authorized Official

Name: TIGRAN SHAHMURADYAN
Title or Position: CEO
Credential:
Phone: 970-550-0000