MEDICARE: PHOENIX BEHAVIORAL GROUP LV LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1386273340
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENIX BEHAVIORAL GROUP LV LLC

Provider Business Mailing Address
First Line	:	1670 E FLAMINGO RD STE B
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-5120
Country	:	US
Telephone Number	:	702-202-4442
Fax Number	:	888-857-3788

Provider Business Practice Location Address
First Line	:	1670 E FLAMINGO RD STE B
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89119-5120
Country	:	US
Telephone Number	:	702-202-4442
Fax Number	:	888-857-3788

Authorized Official
Title or Position	:	MANAGER
Name	:	YESICA Y SANCHEZ
Credential	:
Telephone Number	:	702-202-4442

Provider Enumeration Date	:	04/02/2020
Last Update Date	:	04/02/2020

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