Provider Demographics
NPI:1841464492
Name:PHOENIX HOUSE INC.
Entity type:Organization
Organization Name:PHOENIX HOUSE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:MAGGIO
Authorized Official - Suffix:
Authorized Official - Credentials:BA, CAC-R
Authorized Official - Phone:906-337-0763
Mailing Address - Street 1:57467 WATERWORKS ST
Mailing Address - Street 2:PO BOX 468
Mailing Address - City:CALUMET
Mailing Address - State:MI
Mailing Address - Zip Code:49913-1258
Mailing Address - Country:US
Mailing Address - Phone:906-337-0763
Mailing Address - Fax:906-337-0768
Practice Address - Street 1:57467 WATERWORKS ST
Practice Address - Street 2:
Practice Address - City:CALUMET
Practice Address - State:MI
Practice Address - Zip Code:49913-1258
Practice Address - Country:US
Practice Address - Phone:906-337-0763
Practice Address - Fax:906-337-0768
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI310003324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility