Healthcare Provider Details

I. General information

NPI: 1801578851
Provider Name (Legal Business Name): PHOENIX GERMANO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2023
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1316 APACHE AVE
SANTA FE NM
87505-3212
US

IV. Provider business mailing address

20548 VENTURA BLVD APT 407
WOODLAND HILLS CA
91364-6472
US

V. Phone/Fax

Practice location:
  • Phone: 310-721-4398
  • Fax:
Mailing address:
  • Phone: 310-721-4398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: