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Organization
PHOENIX RESIDENCE INC
Active
Organization
PHOENIX RESIDENCE INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DARLENE M SCOTT (PRESIDENT CEO)
(651) 227-7655
Entity
Organization
Contact information
Practice address
1866 FURNESS STREET, MAPLEWOOD, MN 55109
(651) 777-6349
(651) 779-9492
Mailing address
330 MARIE AVENUE E, WEST ST PAUL, MN 55118-4011
(651) 227-7655
(651) 227-6847
Taxonomy
Speciality
Code
Description
License number
State
315P00000X
Intellectual Disabilities Intermediate Care Facility
Primary
800870
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
443545100
—
MN
Enumeration date
10/03/2006
Last updated
07/02/2008
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