MEDICARE: PHOENIX RESIDENCE, INC.

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	315P00000X	Intellectual Disabilities Intermediate Care Facility	1032532 1 RS	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649376005
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENIX RESIDENCE, INC.

Provider Business Mailing Address
First Line	:	330 MARIE AVE E
Second Line	:
City	:	WEST ST PAUL
State	:	MN
Zip	:	55118-4011
Country	:	US
Telephone Number	:	651-227-7655
Fax Number	:	651-227-6847

Provider Business Practice Location Address
First Line	:	7717 LONG LAKE RD
Second Line	:
City	:	MOUNDS VIEW
State	:	MN
Zip	:	55112-6205
Country	:	US
Telephone Number	:	763-398-3812
Fax Number	:	763-398-3813

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	SCOTT M DARLENE
Credential	:
Telephone Number	:	651-227-7655

Provider Enumeration Date	:	09/15/2006
Last Update Date	:	07/01/2008

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