=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831238385
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PHOENIX HOUSE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 35TH AVE
-----------------------------------------------------
City | TUSCALOOSA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35401-1330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-758-3867
-----------------------------------------------------
Fax | 205-758-3803
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 35TH AVE
-----------------------------------------------------
City | TUSCALOOSA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35401-1330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-758-3867
-----------------------------------------------------
Fax | 205-758-3803
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. RONALD L COLVIN
-----------------------------------------------------
Credential | CADP
-----------------------------------------------------
Telephone | 205-758-3867
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------