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General NPI Number Information
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NPI Number | 1083146013
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Entity Type | Organization
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Legal Business Name | PHOENIX GROUP HOME LLC
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Dates
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Enumeration Date | 03/29/2017
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Last Update Date | 11/12/2024
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Provider Practice Location Address
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Address Line | 902 GALLIA ST
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City | PORTSMOUTH
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State | OH
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Zip | 45662-4139
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Country | US
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Telephone | 740-529-2125
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Fax | 740-529-2126
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Provider Business Mailing Address
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Address Line | PO BOX 900926
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City | SANDY
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State | UT
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Zip | 84090-0926
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Country | US
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Telephone | 740-858-1659
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Fax | 513-221-2093
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Authorized Official
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Title or Position | OWNER
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Name | MR. MARSHAL LUNT
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Credential |
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Telephone | 801-560-3822
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3245S0500X
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Taxonomy Name | Children's Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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