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General NPI Number Information
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NPI Number | 1508045998
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Entity Type | Organization
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Legal Business Name | PHOENIX BRIDGE COMMUNITY SUPPORT
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Dates
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Enumeration Date | 11/01/2007
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Last Update Date | 11/01/2007
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Provider Practice Location Address
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Address Line | 814 BRADLEY ST
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City | BURLINGTON
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State | NC
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Zip | 27215-6806
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Country | US
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Telephone | 336-222-8522
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Fax | 336-222-8533
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Provider Business Mailing Address
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Address Line | 909 A SOUTH MAIN STREET
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City | BURLINGTON
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State | NC
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Zip | 27215-5756
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Country | US
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Telephone | 336-222-8522
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Fax | 336-222-8533
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Authorized Official
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Title or Position | PROGRAM DIRECTOR
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Name | MISS WENDY RENEE JONES
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Credential |
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Telephone | 336-222-8522
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number | MHL-001-121
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License Number State | NC
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