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General NPI Number Information
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NPI Number | 1851821680
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Entity Type | Organization
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Legal Business Name | PHYSICIAN HEALTH COLLABORATIVE CORPORATION
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Dates
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Enumeration Date | 06/14/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 11497 BARTLETT AVE STE B1
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City | ADELANTO
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State | CA
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Zip | 92301-1901
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Country | US
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Telephone | 760-246-6600
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Fax | 760-955-8558
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Provider Business Mailing Address
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Address Line | 11497 BARTLETT AVE STE B1
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City | ADELANTO
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State | CA
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Zip | 92301-1901
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Country | US
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Telephone | 760-246-6600
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Fax | 760-955-8558
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Authorized Official
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Title or Position | SOLE SHAREHOLDER
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Name | STUART LEVINE
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Credential | MD
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Telephone | 760-955-9555
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | G57910
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | A87666
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License Number State | CA
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