Provider Demographics
NPI:1083146013
Name:PHOENIX GROUP HOME LLC
Entity Type:Organization
Organization Name:PHOENIX GROUP HOME LLC
Other - Org Name:PATH INTEGRATED HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARSHAL
Authorized Official - Middle Name:
Authorized Official - Last Name:LUNT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-560-3822
Mailing Address - Street 1:3012 GLENMORE AVE
Mailing Address - Street 2:SUITE 14
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45238-2269
Mailing Address - Country:US
Mailing Address - Phone:513-221-3000
Mailing Address - Fax:513-221-2093
Practice Address - Street 1:902 GALLIA ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-4139
Practice Address - Country:US
Practice Address - Phone:740-529-2125
Practice Address - Fax:740-529-2126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-29
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, ChildrenGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0241576Medicaid