Provider Demographics
NPI:1669514725
Name:PHOENIX BRIDGE GROUP HOMES, INC.
Entity type:Organization
Organization Name:PHOENIX BRIDGE GROUP HOMES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
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 1:120 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GRAHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27253-2808
Mailing Address - Country:US
Mailing Address - Phone:336-222-8522
Mailing Address - Fax:336-222-8533
Practice Address - Street 1:3309 N NC HIGHWAY 49 # A
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27217-8589
Practice Address - Country:US
Practice Address - Phone:336-578-0540
Practice Address - Fax:336-222-8533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
NCMHL 001-120322D00000X
NCMHL 001-100322D00000X
NCMHL 001-121322D00000X
NCMHL -001 - 135322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered251B00000XAgenciesCase Management
Not Answered322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603578Medicaid
NC8301363Medicaid
NC6603321Medicaid
NC6603357Medicaid
NC6603972Medicaid