Provider Demographics
NPI:1417006503
Name:PHOENIX RECOVERY CENTER INC
Entity Type:Organization
Organization Name:PHOENIX RECOVERY CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:KINNEBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:410-671-7374
Mailing Address - Street 1:107 EDGEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:21040
Mailing Address - Country:US
Mailing Address - Phone:410-671-7374
Mailing Address - Fax:410-679-7757
Practice Address - Street 1:107 EDGEWOOD RD
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:MD
Practice Address - Zip Code:21040
Practice Address - Country:US
Practice Address - Phone:410-671-7374
Practice Address - Fax:410-679-7757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13137261QR0405X
261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder