Healthcare Provider Details

I. General information

NPI: 1245324920
Provider Name (Legal Business Name): PHOENIX RESIDENCE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1866 FURNESS STREET
MAPLEWOOD MN
55109
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 651-777-6349
  • Fax: 651-779-9492
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 Number800870
License Number StateMN

VIII. Authorized Official

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