Provider Demographics
NPI:1518302801
Name:THE PHOENIX GROUP, LLC
Entity Type:Organization
Organization Name:THE PHOENIX GROUP, LLC
Other - Org Name:THE PHOENIX GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OPERATIONS DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:DUANE
Authorized Official - Last Name:MCMILLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-355-8665
Mailing Address - Street 1:200 S 37TH ST APT F
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51501-3284
Mailing Address - Country:US
Mailing Address - Phone:712-355-8665
Mailing Address - Fax:
Practice Address - Street 1:200 S 37TH ST APT F
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51501-3284
Practice Address - Country:US
Practice Address - Phone:712-355-8665
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-01
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA489DLC-456043320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities