Provider Demographics
NPI:1336654854
Name:PHOENIX GROUP HOME, LLC
Entity type:Organization
Organization Name:PHOENIX GROUP HOME, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ABBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARPENTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-794-6285
Mailing Address - Street 1:3012 GLENMORE AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45238-2258
Mailing Address - Country:US
Mailing Address - Phone:740-858-1659
Mailing Address - Fax:740-876-9213
Practice Address - Street 1:3012 GLENMORE AVE STE 104
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45238-2258
Practice Address - Country:US
Practice Address - Phone:740-858-1659
Practice Address - Fax:740-876-9213
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-12-06
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children