Provider Demographics
NPI:1588855787
Name:PHOENIX HOME FOR BOYS
Entity Type:Organization
Organization Name:PHOENIX HOME FOR BOYS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:RONDA
Authorized Official - Middle Name:MITCHELL
Authorized Official - Last Name:BYTHEWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-439-9911
Mailing Address - Street 1:PO BOX 2386
Mailing Address - Street 2:
Mailing Address - City:MORGANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28680-2386
Mailing Address - Country:US
Mailing Address - Phone:828-439-9911
Mailing Address - Fax:828-439-9911
Practice Address - Street 1:117 WILLIAM PARKS LN
Practice Address - Street 2:
Practice Address - City:MORGANTON
Practice Address - State:NC
Practice Address - Zip Code:28655-9173
Practice Address - Country:US
Practice Address - Phone:828-584-1589
Practice Address - Fax:828-584-1589
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHOENIX GROUP HOMES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-08-05
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-012-009322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603042Medicaid