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General NPI Number Information
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NPI Number | 1831248012
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Entity Type | Organization
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Legal Business Name | PHOENIX ISL
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Dates
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Enumeration Date | 01/09/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 26823 S BROOKHART DR
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City | HARRISONVILLE
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State | MO
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Zip | 64701-6357
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Country | US
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Telephone | 816-380-0723
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Fax | 816-380-5083
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Provider Business Mailing Address
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Address Line | 26823 S BROOKHART DR
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City | HARRISONVILLE
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State | MO
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Zip | 64701-6357
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Country | US
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Telephone | 816-380-0723
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Fax | 816-380-5083
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Authorized Official
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Title or Position | PROVIDER
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Name | MR. DALE KILGORE
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Credential |
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Telephone | 816-380-0723
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number |
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License Number State | MO
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