MEDICARE: PHOENIX HOMES, 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	322D00000X	Emotionally Disturbed Childrens' Residential Treatment Facility	046478	AL
2	251S00000X	Community/Behavioral Health Agency	40064	RI
3	251S00000X	Community/Behavioral Health Agency	00294	MD
4	251S00000X	Community/Behavioral Health Agency	500544	KY
5	251S00000X	Community/Behavioral Health Agency	SO10124A	TN
6	251S00000X	Community/Behavioral Health Agency	SO10103A	TN
7	251S00000X	Community/Behavioral Health Agency	SO10102A	TN
8	251S00000X	Community/Behavioral Health Agency	496	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609088798
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENIX HOMES, INC

Provider Business Mailing Address
First Line	:	233 N MAIN ST
Second Line	:
City	:	DELPHOS
State	:	OH
Zip	:	45891
Country	:	US
Telephone Number	:	419-692-2421
Fax Number	:	419-692-2300

Provider Business Practice Location Address
First Line	:	233 N MAIN ST
Second Line	:
City	:	DELPHOS
State	:	OH
Zip	:	45891
Country	:	US
Telephone Number	:	419-692-2421
Fax Number	:	419-692-2300

Authorized Official
Title or Position	:	CEO
Name	:	BRUCE MAAG
Credential	:	MS., LPC, LSW
Telephone Number	:	419-692-2421

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	07/22/2008

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Directions to “PHOENIX HOMES, INC ” Practice Location

Language	Start Address	Practice Location

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