Provider Demographics
NPI:1508045998
Name:PHOENIX BRIDGE COMMUNITY SUPPORT
Entity Type:Organization
Organization Name:PHOENIX BRIDGE COMMUNITY SUPPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-222-8522
Mailing Address - Street 1:909 A SOUTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27215-5756
Mailing Address - Country:US
Mailing Address - Phone:336-222-8522
Mailing Address - Fax:336-222-8533
Practice Address - Street 1:814 BRADLEY ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-6806
Practice Address - Country:US
Practice Address - Phone:336-222-8522
Practice Address - Fax:336-222-8533
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHOENIX BRIDGE GROUP HOME, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-01
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-001-121322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603578Medicaid