Provider Demographics
NPI:1770828873
Name:THE PHOENIX RECOVERY CENTER LLC
Entity Type:Organization
Organization Name:THE PHOENIX RECOVERY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:TIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-438-3185
Mailing Address - Street 1:11762 S STATE ST
Mailing Address - Street 2:SUITE 360
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-7155
Mailing Address - Country:US
Mailing Address - Phone:801-571-6798
Mailing Address - Fax:801-619-2016
Practice Address - Street 1:489 W. SOUTH JORDAN PARKWAY
Practice Address - Street 2:
Practice Address - City:STE 500
Practice Address - State:UT
Practice Address - Zip Code:84095
Practice Address - Country:US
Practice Address - Phone:801-438-3185
Practice Address - Fax:801-438-3184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-01
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
323P00000X
UT20020324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility