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
1685 HOWARD ST, MAPLEWOOD, MN 55109
(651) 777-6754
(651) 779-9339
Mailing address
330 MARIE AVE 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
801102
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
273545800
—
MN
Enumeration date
10/10/2006
Last updated
07/01/2008
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