NPIMap

Organization Active NPI

Phoenix Residence, Inc.

  • Intellectual Disabilities Intermediate Care Facility
  • Mounds View, MN
National Provider Identifier
1649376005
Registry record updated Jul 1, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Intellectual Disabilities Intermediate Care FacilityTaxonomy code 315P00000X
License
1032532 1 RS Issued in MN
Legal business name
PHOENIX RESIDENCE, INC.
Practice address
7717 Long Lake Rd
Mounds View, MN 55112-6205
Phone
(763) 398-3812
Fax
(763) 398-3813
NPI assigned
Sep 15, 2006
Last updated
Jul 1, 2008By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 1, 2008

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

Authorized official

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

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Intellectual Disabilities Intermediate Care Facility 315P00000X 1032532 1 RS MN Primary

Addresses

Primary practice location

7717 Long Lake Rd
Mounds View, MN 55112-6205

Mailing address

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

Other identifiers 1

IdentifierTypeStateIssuer
355474100MedicaidMN

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Not listed in the public Medicare enrollment file

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1649376005. Details of each certification follow.

  • CCN 24G510 Intermediate care facility for individuals with intellectual disabilities · Active · Name & address match · Details

Intermediate care facility for individuals with intellectual disabilities certification: CCN 24G510

Name & address match This certification has no NPI in the Medicare enrollment files. CMS publishes enrollment files for six facility types only, so it was connected to this NPI by matching the name and address CMS publishes for it.

Legal name
PHOENIX AT LUDDEN
Certification status
Active
Provider type (POS)
Intermediate care facility for individuals with intellectual disabilities
Participating since
May 17, 2005
Last certification
Dec 11, 2025
Beds
6
Ownership / control type
Private (non-profit)
Facility address
7717 Long Lake Road
Mounds View, MN 55112

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.

NPI Registry JSON

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

{
    "created_epoch": "1158278400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1214870400000",
    "number": "1649376005",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "330 MARIE AVE 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": "7717 LONG LAKE RD",
            "city": "MOUNDS VIEW",
            "state": "MN",
            "postal_code": "551126205",
            "telephone_number": "763-398-3812",
            "fax_number": "763-398-3813"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PHOENIX RESIDENCE, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-09-15",
        "last_updated": "2008-07-01",
        "status": "A",
        "authorized_official_last_name": "DARLENE",
        "authorized_official_first_name": "SCOTT",
        "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": "1032532 1 RS",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "355474100",
            "state": "MN"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Mounds View, MN

Sources for this page

Verify at the official NPI Registry.