Provider Demographics
NPI:1437967700
Name:PHOENIX RESIDENTIAL CARE
Entity type:Organization
Organization Name:PHOENIX RESIDENTIAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:RONDA
Authorized Official - Middle Name:S
Authorized Official - Last Name:CHAMBERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-254-4145
Mailing Address - Street 1:6605 E MARSHVILLE BLVD
Mailing Address - Street 2:
Mailing Address - City:MARSHVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28103-1199
Mailing Address - Country:US
Mailing Address - Phone:704-327-4444
Mailing Address - Fax:
Practice Address - Street 1:5003 HWY 74 EAST
Practice Address - Street 2:
Practice Address - City:WINGATE
Practice Address - State:NC
Practice Address - Zip Code:28174
Practice Address - Country:US
Practice Address - Phone:704-327-4444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-19
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities