Healthcare Provider Details

I. General information

NPI: 1174484596
Provider Name (Legal Business Name): PHOENIX REHABILITATION SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2025
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2184 S WILDERNESS RD
MOUNT VERNON KY
40456-7631
US

IV. Provider business mailing address

2184 S WILDERNESS RD
MOUNT VERNON KY
40456-7631
US

V. Phone/Fax

Practice location:
  • Phone: 606-256-0000
  • Fax: 606-256-0008
Mailing address:
  • Phone: 606-256-0000
  • Fax: 606-256-0008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: TINTISHA CLANTON
Title or Position: CREDENTIALING/BILLING MANAGER
Credential:
Phone: 502-229-7820