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
2465 CARVER AVE, MAPLEWOOD, MN 55119
(651) 702-8995
(651) 702-2511
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
1033706 1 RS
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
081135100
—
MN
Enumeration date
09/20/2006
Last updated
07/01/2008
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