Provider Demographics
NPI:1114352192
Name:NEW EXODOS
Entity Type:Organization
Organization Name:NEW EXODOS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PHIL
Authorized Official - Middle Name:
Authorized Official - Last Name:MC ILVEEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-368-8966
Mailing Address - Street 1:5320 N 16TH ST
Mailing Address - Street 2:204
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-3220
Mailing Address - Country:US
Mailing Address - Phone:602-368-8966
Mailing Address - Fax:
Practice Address - Street 1:5320 N 16TH ST
Practice Address - Street 2:204
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-3220
Practice Address - Country:US
Practice Address - Phone:602-368-8966
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-09
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health