Provider Demographics
NPI:1215702238
Name:PHOENIX RISING
Entity type:Organization
Organization Name:PHOENIX RISING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HOUSE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-425-2921
Mailing Address - Street 1:392 E 3900 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-1615
Mailing Address - Country:US
Mailing Address - Phone:801-425-2921
Mailing Address - Fax:
Practice Address - Street 1:392 E 3900 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-1615
Practice Address - Country:US
Practice Address - Phone:801-425-2921
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-20
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0800XAmbulatory Health Care FacilitiesClinic/CenterRecovery Care