Healthcare Provider Details

I. General information

NPI: 1639247653
Provider Name (Legal Business Name): PHOENIX HOUSE FOUNDATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 W 74TH ST
NEW YORK NY
10023-2301
US

IV. Provider business mailing address

50 JAY ST 3RS FL
BROOKLYN NY
11201-1144
US

V. Phone/Fax

Practice location:
  • Phone: 718-222-6600
  • Fax: 718-576-2866
Mailing address:
  • Phone: 718-222-6600
  • Fax: 718-576-2866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number7002298R
License Number StateNY

VIII. Authorized Official

Name: MR. KEVIN KIRCHOFF
Title or Position: SR. VICE PRESIDENT, CFO
Credential:
Phone: 212-595-5810