Provider Demographics
NPI:1639247653
Name:PHOENIX HOUSE FOUNDATION, INC.
Entity Type:Organization
Organization Name:PHOENIX HOUSE FOUNDATION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. VICE PRESIDENT, CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRCHOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-595-5810
Mailing Address - Street 1:50 JAY ST
Mailing Address - Street 2:3RS FL
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-1144
Mailing Address - Country:US
Mailing Address - Phone:718-222-6600
Mailing Address - Fax:718-576-2866
Practice Address - Street 1:164 W 74TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023-2301
Practice Address - Country:US
Practice Address - Phone:718-222-6600
Practice Address - Fax:718-576-2866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7002298R261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00371673Medicaid