Provider Demographics
NPI:1184475378
Name:PHOENIX RENEWAL TREATMENT SERVICES
Entity type:Organization
Organization Name:PHOENIX RENEWAL TREATMENT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CORY
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:SOMLAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-529-8981
Mailing Address - Street 1:12401 MINNETONKA BLVD
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-3971
Mailing Address - Country:US
Mailing Address - Phone:952-513-7475
Mailing Address - Fax:952-426-3266
Practice Address - Street 1:12401 MINNETONKA BLVD
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-3971
Practice Address - Country:US
Practice Address - Phone:952-513-7475
Practice Address - Fax:952-426-3266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-27
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility