Provider Demographics
NPI:1780348789
Name:PHOENIX WELLNESS LLC
Entity type:Organization
Organization Name:PHOENIX WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:N
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-609-7334
Mailing Address - Street 1:1600 CHURCHILL DOWNS DR
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-6627
Mailing Address - Country:US
Mailing Address - Phone:704-609-7334
Mailing Address - Fax:855-655-3374
Practice Address - Street 1:1040 EDGEWATER CORPORATE PKWY STE 106
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29707-4526
Practice Address - Country:US
Practice Address - Phone:704-609-7334
Practice Address - Fax:855-655-3374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-26
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Single Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
No251B00000XAgenciesCase Management
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QP2400XAmbulatory Health Care FacilitiesClinic/CenterPrison Health
No261QV0200XAmbulatory Health Care FacilitiesClinic/CenterVA