1841417144 NPI number — PHOENIX GROUP HOMES, INC.

Table of content: (NPI 1841417144)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841417144 NPI number — PHOENIX GROUP HOMES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHOENIX 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:
1841417144
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:
1011 INTERLACHEN PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODBURY
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55125-8852
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-230-0849
Provider Business Mailing Address Fax Number:
651-773-5894

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1936 CRAIG PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAPLEWOOD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55109-2844
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-748-4031
Provider Business Practice Location Address Fax Number:
651-748-4043
Provider Enumeration Date:
04/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SPARKS
Authorized Official First Name:
WENDY
Authorized Official Middle Name:
JEAN
Authorized Official Title or Position:
ASSISTANT DIRECTOR
Authorized Official Telephone Number:
651-230-0849

Provider Taxonomy Codes

  • Taxonomy code: 177F00000X , with the licence number:  1037126-1 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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