Provider Demographics
NPI:1962542423
Name:PHOENIX PROGRAMS OF FLORIDA, INC.
Entity type:Organization
Organization Name:PHOENIX PROGRAMS OF FLORIDA, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VP. & REGIONAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALVAREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-881-1000
Mailing Address - Street 1:510 VONDERBURG DR.
Mailing Address - Street 2:SUITE 301
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-6072
Mailing Address - Country:US
Mailing Address - Phone:813-881-1000
Mailing Address - Fax:813-689-2856
Practice Address - Street 1:510 VONDERBURG DR.
Practice Address - Street 2:SUITE 301
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-6072
Practice Address - Country:US
Practice Address - Phone:813-881-1000
Practice Address - Fax:813-689-2856
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHOENIX HOUSE FOUNDATION, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-07
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1329AD294801251S00000X, 261QR0405X
FL0542AD294801324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Yes251S00000XAgenciesCommunity/Behavioral Health
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL076716600Medicaid