Healthcare Provider Details

I. General information

NPI: 1023654019
Provider Name (Legal Business Name): PHOENIX WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2019
Last Update Date: 11/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 N COAST HWY
NEWPORT OR
97365-3195
US

IV. Provider business mailing address

PO BOX 2082
NEWPORT OR
97365-0150
US

V. Phone/Fax

Practice location:
  • Phone: 541-270-9426
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name: MISS ASHLIEGH VICTORIA RAMIREZ
Title or Position: A&D OUTPATIENT COUNSELOR
Credential: CADC I
Phone: 541-270-9426