Provider Demographics
NPI:1699551754
Name:PHOENIX TREATMENT CENTERS OUTPATIENT DIVISION, LLC
Entity type:Organization
Organization Name:PHOENIX TREATMENT CENTERS OUTPATIENT DIVISION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:SISCO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-367-3980
Mailing Address - Street 1:PO BOX 1285
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41502-1285
Mailing Address - Country:US
Mailing Address - Phone:606-658-3078
Mailing Address - Fax:
Practice Address - Street 1:400 VENTERS LN STE 100
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-3016
Practice Address - Country:US
Practice Address - Phone:606-653-1505
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHOENIX TREATMENT CENTERS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-09-05
Last Update Date:2024-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility