Provider Demographics
NPI:1750522058
Name:PHOENIX OUTDOOR
Entity type:Organization
Organization Name:PHOENIX OUTDOOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:NILSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-668-7590
Mailing Address - Street 1:631 WILLOW CREEK RD
Mailing Address - Street 2:
Mailing Address - City:LEICESTER
Mailing Address - State:NC
Mailing Address - Zip Code:28748-5646
Mailing Address - Country:US
Mailing Address - Phone:828-683-7718
Mailing Address - Fax:828-683-9995
Practice Address - Street 1:631 WILLOW CREEK RD
Practice Address - Street 2:
Practice Address - City:LEICESTER
Practice Address - State:NC
Practice Address - Zip Code:28748-5646
Practice Address - Country:US
Practice Address - Phone:828-683-7718
Practice Address - Fax:828-683-9995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-16
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-011-279322D00000X, 3245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children