=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952676207
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FENIX GROUP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2012
-----------------------------------------------------
Last Update Date | 03/20/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 919 N DYSART RD STE V
-----------------------------------------------------
City | AVONDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85323-1711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-882-2016
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 919 N DYSART RD STE V
-----------------------------------------------------
City | AVONDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85323-1711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-882-2016
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | RON TILLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 623-882-2016
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number | 06262
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------