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PHOENIX RESIDENCE, INC.

Intermediate Care Facility, Mentally Retarded

White Bear Lake, Minnesota

Provider NPI: 1457458812

Organization Information:
Organization Name:  PHOENIX RESIDENCE, INC.


Practice Location:
2168 12TH STREET  WHITE BEAR LAKE, MN 55110 US
Tel: 651-653-3713  Fax: --

Business Mailing Address:
  ,   
Tel: --  Fax: --


Taxonomy:

PrimaryCodeCategory/DescriptionStateLicense Number
Y315P00000XNursing & Custodial Care Facilities
Intermediate Care Facility, Mentally Retarded
MN1032511 1 RS

Other Provider Identifiers:

IssuerNumberStateType
714417200MN05
Code values:
01, Other | 02, Medicare Upin | 04, Medicare Id-Type Unspecified
05, Medicaid | 06, Medicare Oscar/Certification | 07, Medicare NSC | 08, Medicare Pin




MENTALLY RETARDED JOBS MN - Page 1



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