Provider Demographics
NPI:1922610088
Name:EAGLE PHOENIX RESIDENTIAL & BEHAVORIAL HEALTH SERVICES LLC
Entity Type:Organization
Organization Name:EAGLE PHOENIX RESIDENTIAL & BEHAVORIAL HEALTH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:LOTORIA
Authorized Official - Last Name:BALLOU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-429-2649
Mailing Address - Street 1:1345 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24540-3721
Mailing Address - Country:US
Mailing Address - Phone:434-429-2649
Mailing Address - Fax:
Practice Address - Street 1:1345 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24540-3721
Practice Address - Country:US
Practice Address - Phone:434-429-2649
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities