Provider Demographics
NPI:1114345121
Name:PHOENIX WAY, LLC
Entity Type:Organization
Organization Name:PHOENIX WAY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LUCRETIA
Authorized Official - Middle Name:RENE
Authorized Official - Last Name:VAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-789-9564
Mailing Address - Street 1:4142 OLD COLUMBIA RD
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-9352
Mailing Address - Country:US
Mailing Address - Phone:270-283-4352
Mailing Address - Fax:
Practice Address - Street 1:4142 OLD COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-9352
Practice Address - Country:US
Practice Address - Phone:270-283-4352
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-07
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100282470Medicaid