Provider Demographics
NPI:1194963371
Name:PHOENIX HOME #1
Entity type:Organization
Organization Name:PHOENIX HOME #1
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ZULU
Authorized Official - Middle Name:
Authorized Official - Last Name:NWANKWO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-771-4517
Mailing Address - Street 1:2726 NEWSOME ST
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27603-2956
Mailing Address - Country:US
Mailing Address - Phone:919-771-4517
Mailing Address - Fax:919-325-0671
Practice Address - Street 1:2726 NEWSOME ST
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27603-2956
Practice Address - Country:US
Practice Address - Phone:919-771-4517
Practice Address - Fax:919-325-0671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-27
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
092734320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness