Provider Demographics
NPI:1639956527
Name:KENTUCKY PHOENIX PROJECT LLC
Entity Type:Organization
Organization Name:KENTUCKY PHOENIX PROJECT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:
Authorized Official - Last Name:COLLIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-471-4546
Mailing Address - Street 1:PO BOX 126
Mailing Address - Street 2:
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653-0126
Mailing Address - Country:US
Mailing Address - Phone:606-459-5001
Mailing Address - Fax:606-548-5477
Practice Address - Street 1:5230 KY ROUTE 321 STE 6
Practice Address - Street 2:
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-9169
Practice Address - Country:US
Practice Address - Phone:606-459-5001
Practice Address - Fax:606-548-5477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-13
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty