Organization
PHOENIX WAY, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LUCRETIA RENE VAUGHN (PROGRAM DIRECTOR)
(270) 789-9564
Entity
Organization
Contact information
Practice address
4142 OLD COLUMBIA RD, CAMPBELLSVILLE, KY 42718-9352
(270) 283-4352
Mailing address
4142 OLD COLUMBIA RD, CAMPBELLSVILLE, KY 42718-9352
(270) 283-4352
Taxonomy
Speciality
Code
Description
License number
State
251C00000X
Developmentally Disabled Services Day Training Agency
Primary
—
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
7100282470
—
KY
Enumeration date
04/07/2014
Last updated
12/02/2014
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