Provider Demographics
NPI:1669858304
Name:PHOENIX RESOLUTIONS TREATMENT FACILITY
Entity Type:Organization
Organization Name:PHOENIX RESOLUTIONS TREATMENT FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROECHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:EBANKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-584-2395
Mailing Address - Street 1:518 SW PRIMA VISTA BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-8734
Mailing Address - Country:US
Mailing Address - Phone:914-584-2395
Mailing Address - Fax:
Practice Address - Street 1:518 SW PRIMA VISTA BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-8734
Practice Address - Country:US
Practice Address - Phone:914-584-2395
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-05
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder