Provider Demographics
NPI:1912354572
Name:PHOENIX PROGRAMS, INC.
Entity Type:Organization
Organization Name:PHOENIX PROGRAMS, INC.
Other - Org Name:PHOENIX HEALTH PROGRAMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VETERANS SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:L
Authorized Official - Last Name:CAMERON
Authorized Official - Suffix:
Authorized Official - Credentials:RASAC II
Authorized Official - Phone:573-875-8880
Mailing Address - Street 1:90 E LESLIE LANE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65202
Mailing Address - Country:US
Mailing Address - Phone:573-875-8880
Mailing Address - Fax:573-442-3830
Practice Address - Street 1:90 E LESLIE LN
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65202-1535
Practice Address - Country:US
Practice Address - Phone:573-875-8880
Practice Address - Fax:573-442-3830
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-24
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1265757991Medicaid
MO866476609Medicaid
MO1437213634Medicaid