Healthcare Provider Details

I. General information

NPI: 1669212809
Provider Name (Legal Business Name): PHOENIX HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2024
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

767 7TH ST NW
NEW BRIGHTON MN
55112
US

IV. Provider business mailing address

767 7TH ST NW
NEW BRIGHTON MN
55112
US

V. Phone/Fax

Practice location:
  • Phone: 612-298-3561
  • Fax:
Mailing address:
  • Phone: 612-298-3561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: OMAR MOHAMUD
Title or Position: MANAGER
Credential:
Phone: 612-298-3561