Provider Demographics
NPI:1730234709
Name:PHILLIPS, MICHAEL (CP)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9253 HERMOSA AVE
Mailing Address - Street 2:STE C
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-5318
Mailing Address - Country:US
Mailing Address - Phone:909-466-4333
Mailing Address - Fax:909-466-7040
Practice Address - Street 1:9253 HERMOSA AVE
Practice Address - Street 2:STE C
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5854
Practice Address - Country:US
Practice Address - Phone:909-466-4333
Practice Address - Fax:909-466-7040
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2012-11-21
Deactivation Date:2008-12-02
Deactivation Code:
Reactivation Date:2012-09-11
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5566240001Medicare NSC