Provider Demographics
NPI:1003022518
Name:PHOENIX GROUP HOMES, INC.
Entity Type:Organization
Organization Name:PHOENIX GROUP HOMES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:J
Authorized Official - Last Name:SPARKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-230-0849
Mailing Address - Street 1:1011 INTERLACHEN PKWY
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-8852
Mailing Address - Country:US
Mailing Address - Phone:651-230-0849
Mailing Address - Fax:651-773-5894
Practice Address - Street 1:20898 130TH ST
Practice Address - Street 2:
Practice Address - City:NEW RICHLAND
Practice Address - State:MN
Practice Address - Zip Code:56072-3501
Practice Address - Country:US
Practice Address - Phone:507-465-9940
Practice Address - Fax:507-465-9941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1037125-3-DCFC177F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes177F00000XOther Service ProvidersLodgingGroup - Single Specialty