Provider Demographics
NPI:1164675344
Name:PHOENIX GROUP HOMES, INC.
Entity Type:Organization
Organization Name:PHOENIX GROUP HOMES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:MEIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-230-1895
Mailing Address - Street 1:1011 INTERLACHEN PKWY
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-8852
Mailing Address - Country:US
Mailing Address - Phone:651-230-0849
Mailing Address - Fax:651-773-5894
Practice Address - Street 1:227 E MAIN ST
Practice Address - Street 2:SUITE 105
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-7732
Practice Address - Country:US
Practice Address - Phone:507-385-0668
Practice Address - Fax:507-385-0020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-31
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1050058-1-CDT251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health