Provider Demographics
NPI:1972736221
Name:PHOENIX RISING LLC
Entity Type:Organization
Organization Name:PHOENIX RISING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KWAME
Authorized Official - Middle Name:
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-315-6152
Mailing Address - Street 1:3106 E NORTHERN PKWY
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21214-1420
Mailing Address - Country:US
Mailing Address - Phone:410-444-9999
Mailing Address - Fax:410-444-9995
Practice Address - Street 1:3106 E NORTHERN PKWY
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21214-1420
Practice Address - Country:US
Practice Address - Phone:410-444-9999
Practice Address - Fax:410-444-9995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-02
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR2759251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health