Basic Information
| Provider Information | |||||||||
| NPI: | 1083146013 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHOENIX GROUP HOME LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PATH INTEGRATED HEALTHCARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3012 GLENMORE AVE | ||||||||
| Address2: | SUITE 14 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452382269 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132213000 | ||||||||
| FaxNumber: | 5132212093 | ||||||||
| Practice Location | |||||||||
| Address1: | 902 GALLIA ST | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456624139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405292125 | ||||||||
| FaxNumber: | 7405292126 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2017 | ||||||||
| LastUpdateDate: | 05/29/2019 | ||||||||
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| AuthorizedOfficialLastName: | LUNT | ||||||||
| AuthorizedOfficialFirstName: | MARSHAL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8015603822 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3245S0500X | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 0241576 | 05 | OH | MEDICAID |