Healthcare Provider Details

I. General information

NPI: 1881645067
Provider Name (Legal Business Name): PHOENIX SERVICE CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2006
Last Update Date: 07/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number1069741-1-HCBS
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number1069741-1-HCBS
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number1014199-1-WS
License Number StateMN

VIII. Authorized Official

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