Provider Demographics
NPI:1740876242
Name:PHOENIX GOSPEL MISSION, INC. DBA PHOENIX RESCUE MISSION
Entity type:Organization
Organization Name:PHOENIX GOSPEL MISSION, INC. DBA PHOENIX RESCUE MISSION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF PROGRAM OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-419-8194
Mailing Address - Street 1:1540 W VAN BUREN ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85007-2414
Mailing Address - Country:US
Mailing Address - Phone:602-475-1695
Mailing Address - Fax:
Practice Address - Street 1:338 N 15TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85007-2402
Practice Address - Country:US
Practice Address - Phone:602-475-1695
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-18
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health