Provider Demographics
NPI:1194991810
Name:PHOENIX FRONTIER INC.
Entity type:Organization
Organization Name:PHOENIX FRONTIER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:MANGANELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-833-3231
Mailing Address - Street 1:100 LEROY
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14214
Mailing Address - Country:US
Mailing Address - Phone:716-833-3231
Mailing Address - Fax:
Practice Address - Street 1:100 LEROY
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14214
Practice Address - Country:US
Practice Address - Phone:716-833-3231
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-02
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY6075659251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02170923Medicaid
NY01597722Medicaid
NY02559364Medicaid
NY01499949Medicaid
NY02702032Medicaid
NY02003092Medicaid
NY02155008Medicaid
NY01509466Medicaid
NY02617825Medicaid