Provider Demographics
NPI:1427490903
Name:PHOENIX MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:PHOENIX MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHOPEDIC
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:PRATLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-687-6600
Mailing Address - Street 1:3576 ARLINGTON AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-3943
Mailing Address - Country:US
Mailing Address - Phone:951-687-6600
Mailing Address - Fax:951-687-6601
Practice Address - Street 1:353 E 1ST ST
Practice Address - Street 2:
Practice Address - City:CALEXICO
Practice Address - State:CA
Practice Address - Zip Code:92231-2731
Practice Address - Country:US
Practice Address - Phone:951-687-6600
Practice Address - Fax:951-687-6601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-24
Last Update Date:2013-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty