MEDICARE: PHOENIX PROFESSIONAL SERVICES

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1740514579
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENIX PROFESSIONAL SERVICES

Provider Business Mailing Address
First Line	:	PO BOX 1303
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27402-1303
Country	:	US
Telephone Number	:	336-508-4884
Fax Number	:	866-577-9894

Provider Business Practice Location Address
First Line	:	108 N FAYETTEVILLE ST
Second Line	:
City	:	LIBERTY
State	:	NC
Zip	:	27298-3203
Country	:	US
Telephone Number	:	336-508-4884
Fax Number	:	866-577-9894

Authorized Official
Title or Position	:	OWNER
Name	:	RICK BUTLER
Credential	:
Telephone Number	:	336-508-4884

Provider Enumeration Date	:	09/26/2009
Last Update Date	:	09/26/2009

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Directions to “PHOENIX PROFESSIONAL SERVICES ” Practice Location

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