Provider Demographics
NPI:1275073553
Name:PHOENIX RECOVERY CENTER, LLC
Entity Type:Organization
Organization Name:PHOENIX RECOVERY CENTER, LLC
Other - Org Name:PHOENIX INTEGRATED HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BURT
Authorized Official - Middle Name:
Authorized Official - Last Name:DHIRA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-551-4364
Mailing Address - Street 1:5945 SAWMILL RD
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-1623
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5945 SAWMILL RD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-1623
Practice Address - Country:US
Practice Address - Phone:888-932-8364
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-06
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0208901Medicaid