Provider Demographics
NPI:1972059806
Name:PHOENIX HEALING CENTER LLC
Entity Type:Organization
Organization Name:PHOENIX HEALING CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PMH-CNS, APRN-BC
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:FRANCETTE
Authorized Official - Last Name:FLUGEL COLLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:507-421-2737
Mailing Address - Street 1:1812 2ND ST SW
Mailing Address - Street 2:SUITE F
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55902-4127
Mailing Address - Country:US
Mailing Address - Phone:507-322-0222
Mailing Address - Fax:507-322-0223
Practice Address - Street 1:1812 2ND ST SW
Practice Address - Street 2:SUITE F
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55902-4127
Practice Address - Country:US
Practice Address - Phone:507-322-0222
Practice Address - Fax:507-322-0223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 121129-6261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN890000607OtherMEDICARE PTAN