Provider Demographics
NPI:1750494522
Name:PHOENIX WELLNESS GROUP
Entity Type:Organization
Organization Name:PHOENIX WELLNESS GROUP
Other - Org Name:PHOENIX WELLNESS GROUP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:BUSINESS DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:MOSS
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:650-888-2290
Mailing Address - Street 1:3417 VALLE VERDE DR
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-2414
Mailing Address - Country:US
Mailing Address - Phone:707-255-4176
Mailing Address - Fax:
Practice Address - Street 1:3417 VALLE VERDE DR
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-2414
Practice Address - Country:US
Practice Address - Phone:707-255-4172
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2009-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG058061207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ZZZ21593ZMedicare PIN