1356441141 NPI number — PHOENIX HOUSES OF NE

Table of content: (NPI 1356441141)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356441141 NPI number — PHOENIX HOUSES OF NE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHOENIX HOUSES OF NE
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:
Provider Other Organization Name Type Code:
6
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:
1356441141
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
131 WAYLAND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PROVIDENCE
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02906-4303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-331-4250
Provider Business Mailing Address Fax Number:
401-331-5520

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 PIERCE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DUBLIN
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03444-0319
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-563-8501
Provider Business Practice Location Address Fax Number:
603-563-8296
Provider Enumeration Date:
09/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MCENEANEY
Authorized Official First Name:
PATRICK
Authorized Official Middle Name:
Authorized Official Title or Position:
EXETUTIVE DIRECTOR
Authorized Official Telephone Number:
401-331-4250

Provider Taxonomy Codes

  • Taxonomy code: 324500000X , with the licence number:  02724 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1009358 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 80092 . This is a "BCBS" identifier , issued by the state of ( VT ) . This identifiers is of the category "OTHER".




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