Provider Demographics
NPI:1629467972
Name:PHOENIX RESIDENTIAL CENTERS, INC.
Entity Type:Organization
Organization Name:PHOENIX RESIDENTIAL CENTERS, INC.
Other - Org Name:MEREDITH LANE FAMILY HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY JO
Authorized Official - Middle Name:
Authorized Official - Last Name:JASKELA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-428-9082
Mailing Address - Street 1:1954 HUBBARD RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:OH
Mailing Address - Zip Code:44057-2172
Mailing Address - Country:US
Mailing Address - Phone:440-428-9082
Mailing Address - Fax:
Practice Address - Street 1:12345 MEREDITH LN
Practice Address - Street 2:
Practice Address - City:PAINESVILLE
Practice Address - State:OH
Practice Address - Zip Code:44077-9246
Practice Address - Country:US
Practice Address - Phone:440-428-9082
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-09
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities