Provider Demographics
NPI:1558734954
Name:PHOENIX FAMILY LIFE CENTER
Entity Type:Organization
Organization Name:PHOENIX FAMILY LIFE CENTER
Other - Org Name:FIRST CHOICE ADDICTION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:318-787-6612
Mailing Address - Street 1:3746 GOVERNMENT STREET
Mailing Address - Street 2:SUITE 8
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71302
Mailing Address - Country:US
Mailing Address - Phone:318-787-6612
Mailing Address - Fax:318-787-6612
Practice Address - Street 1:3746 GOVERNMENT ST
Practice Address - Street 2:SUITE 8
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71302-3252
Practice Address - Country:US
Practice Address - Phone:318-787-6612
Practice Address - Fax:318-787-6612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-06
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1029101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty