MEDICARE: RISING PHOENIX INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320800000X	Mental Illness Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1477685857
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RISING PHOENIX INC.

Provider Business Mailing Address
First Line	:	603 MONTROSE DRIVE
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27410-1289
Country	:	US
Telephone Number	:	336-855-3744
Fax Number	:	336-855-3744

Provider Business Practice Location Address
First Line	:	603 MONTROSE DRIVE
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27410-1289
Country	:	US
Telephone Number	:	336-855-3744
Fax Number	:	336-855-3744

Authorized Official
Title or Position	:	OWNER
Name	:	MR. MEL DONTE WESTMORELAND
Credential	:
Telephone Number	:	336-558-5108

Provider Enumeration Date	:	03/11/2007
Last Update Date	:	04/19/2022

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