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General NPI Number Information
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NPI Number | 1245324920
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Entity Type | Organization
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Legal Business Name | PHOENIX RESIDENCE INC
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Dates
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Enumeration Date | 10/03/2006
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Last Update Date | 07/02/2008
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Provider Practice Location Address
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Address Line | 1866 FURNESS STREET
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City | MAPLEWOOD
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State | MN
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Zip | 55109
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Country | US
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Telephone | 651-777-6349
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Fax | 651-779-9492
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Provider Business Mailing Address
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Address Line | 330 MARIE AVENUE E
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City | WEST ST PAUL
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State | MN
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Zip | 55118-4011
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Country | US
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Telephone | 651-227-7655
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Fax | 651-227-6847
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Authorized Official
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Title or Position | PRESIDENT CEO
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Name | DARLENE M SCOTT
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Credential |
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Telephone | 651-227-7655
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number | 800870
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License Number State | MN
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