Provider Demographics
NPI:1033586417
Name:PHOENIX PROVIDERS
Entity Type:Organization
Organization Name:PHOENIX PROVIDERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:AARON
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:VAN PELT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:775-722-0574
Mailing Address - Street 1:3844 JOY LN
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89523
Mailing Address - Country:US
Mailing Address - Phone:775-722-0574
Mailing Address - Fax:
Practice Address - Street 1:3844 JOY LN
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89523
Practice Address - Country:US
Practice Address - Phone:775-722-0574
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-01
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20151498467305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization