NPIMap

Organization Active NPI

Phoenix Residence Inc

  • Intellectual Disabilities Intermediate Care Facility
  • Maplewood, MN
National Provider Identifier
1245324920
Registry record updated Jul 2, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Intellectual Disabilities Intermediate Care FacilityTaxonomy code 315P00000X
License
800870 Issued in MN
Legal business name
PHOENIX RESIDENCE INC
Practice address
1866 Furness Street
Maplewood, MN 55109
Phone
(651) 777-6349
Fax
(651) 779-9492
NPI assigned
Oct 3, 2006
Last updated
Jul 2, 2008By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 2, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Darlene M Scott
Title
President Ceo
Phone
(651) 227-7655

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Intellectual Disabilities Intermediate Care Facility 315P00000X 800870 MN Primary

Addresses

Primary practice location

1866 Furness Street
Maplewood, MN 55109

Mailing address

330 Marie Avenue E
West St Paul, MN 55118-4011
Phone (651) 227-7655

Other identifiers 1

IdentifierTypeStateIssuer
443545100MedicaidMN

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
24D2039459The Phoenix Residence Inc1866 Furness, Maplewood, MN 55109Certificate of waiverApr 9, 2028

National Provider Directory

National Provider Directory
Tax ID family
Phoenix Residence Inc12 organizations share this tax ID, including this one

Other organizations with this tax ID 11

Organizations that report the same tax identification number in the National Provider Directory.

Locations

1866 Furness St
Maplewood, MN 55109
Phone (651) 777-6349

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1159833600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1214956800000",
    "number": "1245324920",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "330 MARIE AVENUE E",
            "city": "WEST ST PAUL",
            "state": "MN",
            "postal_code": "551184011",
            "telephone_number": "651-227-7655",
            "fax_number": "651-227-6847"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1866 FURNESS STREET",
            "city": "MAPLEWOOD",
            "state": "MN",
            "postal_code": "55109",
            "telephone_number": "651-777-6349",
            "fax_number": "651-779-9492"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PHOENIX RESIDENCE INC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-10-03",
        "last_updated": "2008-07-02",
        "status": "A",
        "authorized_official_last_name": "SCOTT",
        "authorized_official_first_name": "DARLENE",
        "authorized_official_middle_name": "M",
        "authorized_official_title_or_position": "PRESIDENT CEO",
        "authorized_official_telephone_number": "651-227-7655"
    },
    "taxonomies": [
        {
            "code": "315P00000X",
            "taxonomy_group": "",
            "desc": "Intermediate Care Facility, Intellectual Disabilities",
            "state": "MN",
            "license": "800870",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "443545100",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Maplewood, MN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 2, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.