Provider Demographics
NPI:1083750228
Name:PHOENIX SUPPORTED LIVING INC.
Entity Type:Organization
Organization Name:PHOENIX SUPPORTED LIVING INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANET
Authorized Official - Middle Name:MELISSA
Authorized Official - Last Name:NEMKOVICH
Authorized Official - Suffix:IX
Authorized Official - Credentials:
Authorized Official - Phone:828-389-1795
Mailing Address - Street 1:2996 NC 69
Mailing Address - Street 2:SUITE 6
Mailing Address - City:HAYESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28904-7257
Mailing Address - Country:US
Mailing Address - Phone:828-389-1795
Mailing Address - Fax:828-389-1658
Practice Address - Street 1:19 645 HWY 19
Practice Address - Street 2:
Practice Address - City:ANDREWS
Practice Address - State:NC
Practice Address - Zip Code:28901
Practice Address - Country:US
Practice Address - Phone:828-389-1795
Practice Address - Fax:828-389-1658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8300926320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300926Medicaid