PHOENIX RESIDENCE INC. NPI 1376649673

NPI Information

  • NPI: 1376649673
  • Provider Name: PHOENIX RESIDENCE, INC.
  • Classification: Intermediate Care Facility, Intellectual Disabilities - 315P00000X
  • Entity Type: Organization
  • CLIA Number: 24D0987947
  • Address: 645 VIKING DR E
    LITTLE CANADA, MN
    ZIP 55117
  • Phone: (651) 294-2076

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NPI Details

PHOENIX RESIDENCE, INC. is an intermediate care facility mentally retarded in Little Canada, MN. The provider is an intermediate care facility providing services for individuals with intellectual disabilities. PHOENIX RESIDENCE, INC. NPI is 1376649673. The provider is registered as an organization entity type.

The provider's business location address is:

645 VIKING DR E
LITTLE CANADA, MN
ZIP 55117-663
Phone: (651) 294-2076
Fax: (651) 294-2077

The provider's authorized official is Darlene M Scott .
The authorized official title is President/ceo and has the following contact phone number (651) 227-7655.

The CLIA number assigned to this NPI record is 24D0987947 - other - 245d provider with a certificate type of Certificate of Waiver.

The enumeration date for this NPI number is 9/15/2006 and was last updated on 7/1/2008.

Taxonomy Codes

The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:

No. Taxonomy Code Taxonomy Clasification Taxonomy Specialization License Number License State Primary
1315P00000XIntermediate Care Facility, Intellectual Disabilities1033704 1 RSMINNESOTAYes

Other Identifiers

The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.

No. Other Provider Identifier Other Provider Identifier Type Other Provider Identifier State Other Provider Identifier Issuer
1957543000MEDICAIDMINNESOTA

What is NPI?

NPI stands for National Provider Identifier. The NPI is a 10-digit identification number that is completely unique. The NPI number by itself does not contain any identifiable information such as a provider’s speciality or location. The NPI is assigned to individuals or organizacions for their lifespan and it is independent of key provider information type updates like a change of practices, location or speciality.

This page was last updated on: 3/30/2025

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