MEDICARE: PHOENIX SANDS 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	385H00000X	Respite Care

General Provider Information

NPI Number	:	1871427757
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENIX SANDS LLC

Provider Business Mailing Address
First Line	:	2700 SAN PABLO AVE APT 102
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94702-2260
Country	:	US
Telephone Number	:	510-417-0551
Fax Number	:

Provider Business Practice Location Address
First Line	:	2700 SAN PABLO AVE APT 102
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94702-2260
Country	:	US
Telephone Number	:	510-417-0551
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JOSHUA CANTERO
Credential	:
Telephone Number	:	510-417-0551

Provider Enumeration Date	:	06/09/2026
Last Update Date	:	06/09/2026

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