1891737292 NPI number — PHOENIX RISING BEHAVIORAL HEALTHCARE AND RECOVERY INC

Table of content: (NPI 1891737292)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891737292 NPI number — PHOENIX RISING BEHAVIORAL HEALTHCARE AND RECOVERY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHOENIX RISING BEHAVIORAL HEALTHCARE AND RECOVERY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
PHOENIX RISING BHR
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1891737292
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/09/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
624 MARKET AVE N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44702-1017
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-493-4553
Provider Business Mailing Address Fax Number:
330-493-3761

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
624 MARKET AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44702-1017
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-493-4553
Provider Business Practice Location Address Fax Number:
330-493-3762
Provider Enumeration Date:
06/11/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GRUBBS
Authorized Official First Name:
LISA
Authorized Official Middle Name:
K
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
330-493-4553

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QM0850X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0850X , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0855X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2594134 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".