MEDICARE: PHOENIX GROUP HOME, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3245S0500X	Children's Substance Abuse Rehabilitation Facility
2	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1336654854
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENIX GROUP HOME, LLC

Provider Business Mailing Address
First Line	:	3012 GLENMORE AVE STE 104
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45238-2258
Country	:	US
Telephone Number	:	740-858-1659
Fax Number	:	740-876-9213

Provider Business Practice Location Address
First Line	:	3012 GLENMORE AVE STE 104
Second Line	:
City	:	CINCINNATI
State	:	OH
Zip	:	45238-2258
Country	:	US
Telephone Number	:	740-858-1659
Fax Number	:	740-876-9213

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	ABBIE CARPENTER
Credential	:
Telephone Number	:	304-794-6285

Provider Enumeration Date	:	12/06/2017
Last Update Date	:	02/06/2026

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