MEDICARE: PHOENIX SERVICE CORPORATION

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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility	1014199-1-WS	MN
2	251J00000X	Nursing Care Agency		MN
3	251S00000X	Community/Behavioral Health Agency	1069741-1-HCBS	MN
4	251B00000X	Case Management Agency	1069741-1-HCBS	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	:	1881645067
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENIX SERVICE CORPORATION

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	:	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

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

Provider Enumeration Date	:	05/13/2006
Last Update Date	:	07/17/2014

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Directions to “PHOENIX SERVICE CORPORATION ” Practice Location

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