Basic Information
| Provider Information | |||||||||
| NPI: | 1124251426 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | L.P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 796 STRATFORD CT | ||||||||
| Address2: | |||||||||
| City: | LEMOORE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932454391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5598169036 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 83 E SHAW AVE | ||||||||
| Address2: | SUITE # 102 | ||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937107620 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5592260167 | ||||||||
| FaxNumber: | 5592261559 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2009 | ||||||||
| LastUpdateDate: | 02/18/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 167G00000X | 34111 | CA | Y | Nursing Service Providers | Licensed Psychiatric Technician |
No ID Information.