Provider Demographics
NPI:1134605363
Name:PHOENIX WINGS
Entity type:Organization
Organization Name:PHOENIX WINGS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:TURNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-574-0795
Mailing Address - Street 1:18701 GRAND RIVER AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-2214
Mailing Address - Country:US
Mailing Address - Phone:313-574-0795
Mailing Address - Fax:313-557-5129
Practice Address - Street 1:2222 LOTHROP ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48206-2672
Practice Address - Country:US
Practice Address - Phone:313-574-0795
Practice Address - Fax:313-557-5129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-11
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care