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General NPI Number Information
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NPI Number | 1225769847
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Entity Type | Organization
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Legal Business Name | THE PHOENIX RECOVERY SUPPORT SERVICES AND SOBER LIVING ENVIRONMENTS LL
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Dates
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Enumeration Date | 06/23/2022
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Last Update Date | 02/07/2023
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Provider Practice Location Address
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Address Line | 3311 12TH ST NW
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City | CANTON
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State | OH
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Zip | 44708-3909
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Country | US
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Telephone | 234-214-9731
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Fax |
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Provider Business Mailing Address
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Address Line | 3311 12TH ST NW
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City | CANTON
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State | OH
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Zip | 44708-3909
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Country | US
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Telephone | 234-214-9731
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Fax |
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Authorized Official
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Title or Position | CHIEF OPERATING OFFICER
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Name | MR. KOREY ALAN MCCREERY
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Credential | PRSS
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Telephone | 234-214-9731
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 175T00000X
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Taxonomy Name | Peer Specialist
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License Number |
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License Number State |
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