Provider Demographics
NPI:1548617970
Name:PHOENIX RECOVERY, LLC
Entity Type:Organization
Organization Name:PHOENIX RECOVERY, LLC
Other - Org Name:RENEW LIFE PATH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:MARBOIS-SEGALL
Authorized Official - Suffix:
Authorized Official - Credentials:CSAC
Authorized Official - Phone:828-242-1400
Mailing Address - Street 1:14 DILLINGHAM CIR
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28805-9785
Mailing Address - Country:US
Mailing Address - Phone:828-777-7746
Mailing Address - Fax:888-211-2660
Practice Address - Street 1:23 VANCE CRESCENT ST
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28806-3010
Practice Address - Country:US
Practice Address - Phone:828-242-1400
Practice Address - Fax:888-211-2660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-16
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X, 305S00000X
NCCSAC-20579251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No305S00000XManaged Care OrganizationsPoint of Service