Provider Demographics
NPI:1467763276
Name:PHOENIX RECOVERY SERVICES, LLC
Entity Type:Organization
Organization Name:PHOENIX RECOVERY SERVICES, LLC
Other - Org Name:PHOENIX RECOVERY SERVICES, LLC, ISLAND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:RUTH
Authorized Official - Last Name:HUNDAHL
Authorized Official - Suffix:
Authorized Official - Credentials:CDP
Authorized Official - Phone:360-848-8437
Mailing Address - Street 1:1601 E COLLEGE WAY
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-5612
Mailing Address - Country:US
Mailing Address - Phone:360-848-8437
Mailing Address - Fax:360-848-5250
Practice Address - Street 1:31640 SR 20 STE 1
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-3128
Practice Address - Country:US
Practice Address - Phone:360-679-7676
Practice Address - Fax:360-682-5947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-25
Last Update Date:2010-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA15145300261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1994649Medicaid