=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629467972
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHOENIX RESIDENTIAL CENTERS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2015
-----------------------------------------------------
Last Update Date | 01/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12345 MEREDITH LN
-----------------------------------------------------
City | PAINESVILLE
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44077-9246
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-428-9082
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1954 HUBBARD RD
-----------------------------------------------------
City | MADISON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44057-2172
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 440-428-9082
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CONTROLLER
-----------------------------------------------------
Name | MS. MARY JO JASKELA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 440-428-9082
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 315P00000X
-----------------------------------------------------
Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------