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General NPI Number Information
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NPI Number | 1437384518
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Entity Type | Organization
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Legal Business Name | PHOENIXCO.
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Dates
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Enumeration Date | 05/19/2009
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Last Update Date | 05/19/2009
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Provider Practice Location Address
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Address Line | 348 MIRACLE STRIP PKWY SW STE 13
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City | FORT WALTON BEACH
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State | FL
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Zip | 32548-5258
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Country | US
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Telephone | 850-244-2900
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Fax | 850-796-2700
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Provider Business Mailing Address
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Address Line | 36132 EMERALD COAST PKWY
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City | DESTIN
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State | FL
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Zip | 32541-5776
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Country | US
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Telephone | 850-424-3914
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Fax | 850-424-3931
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Authorized Official
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Title or Position | CEO
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Name | ADAM POLLOCK
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Credential |
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Telephone | 337-315-9456
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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