Provider Demographics
NPI:1881645067
Name:PHOENIX SERVICE CORPORATION
Entity Type:Organization
Organization Name:PHOENIX SERVICE CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:DARLENE
Authorized Official - Middle Name:M
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-227-7655
Mailing Address - Street 1:330 MARIE AVE E
Mailing Address - Street 2:
Mailing Address - City:WEST ST PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55118-4011
Mailing Address - Country:US
Mailing Address - Phone:651-227-7655
Mailing Address - Fax:651-227-6847
Practice Address - Street 1:330 MARIE AVE E
Practice Address - Street 2:
Practice Address - City:WEST ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55118-4011
Practice Address - Country:US
Practice Address - Phone:651-227-7655
Practice Address - Fax:651-227-6847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-13
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1069741-1-HCBS251B00000X, 251S00000X
MN251J00000X
MN1014199-1-WS320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No251J00000XAgenciesNursing Care
No251S00000XAgenciesCommunity/Behavioral Health
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN596555100Medicaid