Healthcare Provider Details

I. General information

NPI: 1134226509
Provider Name (Legal Business Name): PHOENIX RESIDENCE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2465 CARVER AVE
MAPLEWOOD MN
55119
US

IV. Provider business mailing address

330 MARIE AVE E
WEST ST PAUL MN
55118-4011
US

V. Phone/Fax

Practice location:
  • Phone: 651-702-8995
  • Fax: 651-702-2511
Mailing address:
  • Phone: 651-227-7655
  • Fax: 651-227-6847

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number1033706 1 RS
License Number StateMN

VIII. Authorized Official

Name: DARLENE M SCOTT
Title or Position: PRESIDENT/CEO
Credential:
Phone: 651-227-7655