Provider Demographics
NPI:1508379553
Name:PHS MEDICAL INC
Entity Type:Organization
Organization Name:PHS MEDICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:STACY
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, ACNP-BC
Authorized Official - Phone:805-208-0434
Mailing Address - Street 1:5268 HUCKLEBERRY OAK ST
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-4503
Mailing Address - Country:US
Mailing Address - Phone:805-208-0434
Mailing Address - Fax:805-578-2371
Practice Address - Street 1:5268 HUCKLEBERRY OAK ST
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93063-4503
Practice Address - Country:US
Practice Address - Phone:805-208-0434
Practice Address - Fax:805-578-2371
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-13
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP15005363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty