MEDICARE: FENIX COLLECTIVE INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	171400000X	Health & Wellness Coach
2	251B00000X	Case Management Agency
3	251S00000X	Community/Behavioral Health Agency
4	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
5	175T00000X	Peer Specialist

General Provider Information

NPI Number	:	1306694278
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FENIX COLLECTIVE INC

Provider Business Mailing Address
First Line	:	5222 SPLIT OAK DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28227-0327
Country	:	US
Telephone Number	:	704-231-1079
Fax Number	:

Provider Business Practice Location Address
First Line	:	5222 SPLIT OAK DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28227-0327
Country	:	US
Telephone Number	:	704-231-1079
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MRS. JESSICA ANNE SUMMERS
Credential	:	NCCPSS
Telephone Number	:	704-231-1079

Provider Enumeration Date	:	05/07/2024
Last Update Date	:	05/07/2024

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