1669514725 NPI number — PHOENIX BRIDGE GROUP HOMES, INC.

Table of content: (NPI 1669514725)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669514725 NPI number — PHOENIX BRIDGE GROUP HOMES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHOENIX BRIDGE GROUP HOMES, 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:
Provider Other Organization Name Type Code:
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:
1669514725
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:
120 S MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAHAM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27253-2808
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-222-8522
Provider Business Mailing Address Fax Number:
336-222-8533

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3309 N NC HIGHWAY 49 # A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURLINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27217-8589
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-578-0540
Provider Business Practice Location Address Fax Number:
336-222-8533
Provider Enumeration Date:
02/13/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
JONES
Authorized Official First Name:
WENDY
Authorized Official Middle Name:
RENEE
Authorized Official Title or Position:
PROGRAM MANAGER
Authorized Official Telephone Number:
336-222-8522

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 322D00000X , with the licence number: MHL 001-120 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 322D00000X , with the licence number: MHL 001-100 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 322D00000X , with the licence number: MHL 001-121 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 322D00000X , with the licence number: MHL -001 - 135 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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

  • Identifier: 6603578 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8301363 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6603321 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6603357 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6603972 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".