Healthcare Provider Details

I. General information

NPI: 1811100282
Provider Name (Legal Business Name): PHOENIX GROUP HOMES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2371 HIGHWOOD AVE E
MAPLEWOOD MN
55119-5801
US

IV. Provider business mailing address

1011 INTERLACHEN PKWY
WOODBURY MN
55125-8852
US

V. Phone/Fax

Practice location:
  • Phone: 651-773-1142
  • Fax: 651-773-5894
Mailing address:
  • Phone: 651-230-0849
  • Fax: 651-773-5894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number1037126-2-DCFC
License Number StateMN

VIII. Authorized Official

Name: MRS. WENDY JEAN SPARKS
Title or Position: ASSISTANT DIRECTOR
Credential:
Phone: 651-230-0849