Provider Demographics
NPI:1952676207
Name:FENIX GROUP, LLC
Entity Type:Organization
Organization Name:FENIX GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RON
Authorized Official - Middle Name:
Authorized Official - Last Name:TILLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:623-882-2016
Mailing Address - Street 1:919 N DYSART RD
Mailing Address - Street 2:STE V
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-1711
Mailing Address - Country:US
Mailing Address - Phone:623-882-2016
Mailing Address - Fax:
Practice Address - Street 1:919 N DYSART RD
Practice Address - Street 2:STE V
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-1711
Practice Address - Country:US
Practice Address - Phone:623-882-2016
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-20
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ06262251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services