1083146013 NPI number — PHOENIX GROUP HOME LLC

Table of content: (NPI 1083146013)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083146013 NPI number — PHOENIX GROUP HOME LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHOENIX GROUP HOME LLC
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:
PATH INTEGRATED HEALTHCARE
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:
1083146013
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/29/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3012 GLENMORE AVE
Provider Second Line Business Mailing Address:
SUITE 14
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45238-2269
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-221-3000
Provider Business Mailing Address Fax Number:
513-221-2093

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
902 GALLIA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTSMOUTH
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45662-4139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-529-2125
Provider Business Practice Location Address Fax Number:
740-529-2126
Provider Enumeration Date:
03/29/2017

Additional Information

Authorized Official

Authorized Official Last Name:
LUNT
Authorized Official First Name:
MARSHAL
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
801-560-3822

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3245S0500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0241576 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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