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General NPI Number Information
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NPI Number | 1750494522
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Entity Type | Organization
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Legal Business Name | PHOENIX WELLNESS GROUP
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Dates
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Enumeration Date | 08/16/2006
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Last Update Date | 03/23/2009
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Provider Practice Location Address
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Address Line | 3417 VALLE VERDE DR
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City | NAPA
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State | CA
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Zip | 94558-2414
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Country | US
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Telephone | 707-255-4172
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Fax |
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Provider Business Mailing Address
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Address Line | 3417 VALLE VERDE DR
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City | NAPA
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State | CA
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Zip | 94558-2414
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Country | US
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Telephone | 707-255-4176
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Fax |
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Authorized Official
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Title or Position | BUSINESS DIRECTOR
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Name | MRS. BARBARA MOSS KELLER
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Credential | LCSW
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Telephone | 650-888-2290
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | G058061
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License Number State | CA
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