Provider Demographics
NPI:1821429267
Name:PHOENIX RESIDENTIAL CENTERS, INC.
Entity Type:Organization
Organization Name:PHOENIX RESIDENTIAL CENTERS, INC.
Other - Org Name:HEISLEY FAMILY HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY JO
Authorized Official - Middle Name:
Authorized Official - Last Name:JASKELA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-428-9082
Mailing Address - Street 1:PO BOX 40
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:OH
Mailing Address - Zip Code:44057-0040
Mailing Address - Country:US
Mailing Address - Phone:440-428-9082
Mailing Address - Fax:440-428-5399
Practice Address - Street 1:5422 W HEISLEY RD
Practice Address - Street 2:
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060-1751
Practice Address - Country:US
Practice Address - Phone:440-352-1105
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-11
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities