Provider Demographics
NPI:1679707574
Name:PHOENIX HOMES #2
Entity type:Organization
Organization Name:PHOENIX HOMES #2
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LOTANNA
Authorized Official - Middle Name:OMEZE
Authorized Official - Last Name:NWANKWO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-522-9896
Mailing Address - Street 1:5628 MILLRACE TRL
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27606-9227
Mailing Address - Country:US
Mailing Address - Phone:919-522-9896
Mailing Address - Fax:919-231-1456
Practice Address - Street 1:5628 MILLRACE TRL
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27606-9227
Practice Address - Country:US
Practice Address - Phone:919-522-9896
Practice Address - Fax:919-231-1456
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-06
Last Update Date:2009-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-092-741320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities