Provider Demographics
NPI:1548507304
Name:PHOENIX RAISING VETERAN SERVICES INC.
Entity type:Organization
Organization Name:PHOENIX RAISING VETERAN SERVICES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:
Authorized Official - Last Name:SAVOIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-305-0934
Mailing Address - Street 1:2000 CALIFORNIA AVENUE
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70062
Mailing Address - Country:US
Mailing Address - Phone:504-305-0934
Mailing Address - Fax:
Practice Address - Street 1:2000 CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70062-5837
Practice Address - Country:US
Practice Address - Phone:504-305-0934
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:YES I CAN, EXCEEDING LIFE'S CHALLENGES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-01-12
Last Update Date:2013-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2203781259305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service