Provider Demographics
NPI:1477254522
Name:PHILLIP, CHRISTOPHER LEE
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:LEE
Last Name:PHILLIP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4885 BLACK BART TRL
Mailing Address - Street 2:
Mailing Address - City:REDWOOD VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95470-9410
Mailing Address - Country:US
Mailing Address - Phone:707-322-6802
Mailing Address - Fax:
Practice Address - Street 1:4885 BLACK BART TRL
Practice Address - Street 2:
Practice Address - City:REDWOOD VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95470-9410
Practice Address - Country:US
Practice Address - Phone:707-322-6802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-15
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA8438345172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver