Provider Demographics
NPI:1033298864
Name:PHOENIX SUPPORTED LIVING INC
Entity Type:Organization
Organization Name:PHOENIX SUPPORTED LIVING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:J
Authorized Official - Last Name:SCHMIDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-389-1795
Mailing Address - Street 1:2996 NC 69 S
Mailing Address - Street 2:SUITE #6
Mailing Address - City:HAYESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28904
Mailing Address - Country:US
Mailing Address - Phone:828-389-1795
Mailing Address - Fax:828-389-1658
Practice Address - Street 1:2996 NC 69 S
Practice Address - Street 2:SUITE #6
Practice Address - City:HAYESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28904
Practice Address - Country:US
Practice Address - Phone:828-389-1795
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804847Medicaid
NC8300648Medicaid
NC8300925Medicaid
NC7804651Medicaid
NC7805099Medicaid
NC8300971Medicaid
NC3409428Medicaid
NC8300926Medicaid
NC8300927Medicaid
NC8301106Medicaid
NC7804263Medicaid
NC8600541Medicaid
NC7805326Medicaid
NC7805529Medicaid