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General NPI Number Information
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NPI Number | 1215482450
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Entity Type | Organization
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Legal Business Name | PHOENIX STAR INSURANCE
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Dates
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Enumeration Date | 08/17/2016
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Last Update Date | 08/17/2016
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Provider Practice Location Address
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Address Line | 10130 GARDEN GROVE BLVD
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City | GARDEN GROVE
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State | CA
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Zip | 92844-1689
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Country | US
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Telephone | 714-876-7502
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Fax |
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Provider Business Mailing Address
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Address Line | 10130 GARDEN GROVE BLVD
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City | GARDEN GROVE
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State | CA
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Zip | 92844-1689
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | AGENCY OWNER
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Name | ALLAN LY
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Credential |
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Telephone | 714-867-3977
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251X00000X
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Taxonomy Name | Supports Brokerage Agency
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License Number | 0K71317
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License Number State | CA
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