| Organization Name: | PHOENIX RESIDENCE, INC. |
| NPI Number: | 1376649673 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | DARLENE M SCOTT (PRESIDENT/CEO) |
| Mailing Address: | 645 Viking Dr E Little Canada |
| State: | MN US |
| Postal Code: | 551171663 |
| Phone Number: | 6512942076 |
| Fax Number: | 6512942077 |
| NPI Enumeration Date: | 09/15/2006 |
| NPI Last Update Date: | 07/01/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 315P00000X |
| License Number: | 1033704 1 RS |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MN |
| Taxonomy Type: | Nursing & Custodial Care Facilities |
| Taxonomy Classification: | Intermediate Care Facility, Mentally Retarded |
| Taxonomy Specialization: | |
| Taxonomy Definition: | (1) A public institution for care of the mentally retarded or people with related conditions. (2) An institution giving active treatment to mentally retarded or developmentally disabled persons or persons with related conditions. The primary purpose of the institution is to provide health or rehabilitative services to such individuals. |