Healthcare Provider Details

I. General information

NPI: 1073737813
Provider Name (Legal Business Name): PHOENIX CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3915 GOLDEN VALLEY RD
MINNEAPOLIS MN
55422-4249
US

IV. Provider business mailing address

514 SAINT PETER ST SUITE 220
SAINT PAUL MN
55102-1001
US

V. Phone/Fax

Practice location:
  • Phone: 651-287-8781
  • Fax: 651-287-8782
Mailing address:
  • Phone: 651-287-8781
  • Fax: 651-287-8782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MRS. AJ BURTON
Title or Position: BUSINESS MANAGER
Credential:
Phone: 651-287-8781