Healthcare Provider Details

I. General information

NPI: 1699440263
Provider Name (Legal Business Name): PHOENIX TREATMENT CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2021
Last Update Date: 08/15/2021
Certification Date: 08/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4114 1ST AVE
NITRO WV
25143-1304
US

IV. Provider business mailing address

PO BOX 11908
CHARLESTON WV
25339-1908
US

V. Phone/Fax

Practice location:
  • Phone: 304-755-0119
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MOHAMMAD KALOU
Title or Position: OWNER
Credential: MD
Phone: 304-688-7027