Provider Demographics
NPI:1760062236
Name:PHOENIX RISING PNCC LLC
Entity Type:Organization
Organization Name:PHOENIX RISING PNCC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:BERNARD
Authorized Official - Last Name:GAMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-349-8560
Mailing Address - Street 1:423 W CENTER ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-2724
Mailing Address - Country:US
Mailing Address - Phone:262-349-8560
Mailing Address - Fax:414-635-3157
Practice Address - Street 1:423 W CENTER ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-2724
Practice Address - Country:US
Practice Address - Phone:262-349-8560
Practice Address - Fax:414-635-3157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-09
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management