Provider Demographics
NPI:1730856253
Name:PHOENIX HEALTH ENTERPRISES
Entity type:Organization
Organization Name:PHOENIX HEALTH ENTERPRISES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MCKENZIE
Authorized Official - Middle Name:REILE
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, APRN, FNP-C
Authorized Official - Phone:701-502-4669
Mailing Address - Street 1:PO BOX 7433
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58507-7433
Mailing Address - Country:US
Mailing Address - Phone:701-502-4669
Mailing Address - Fax:833-493-3699
Practice Address - Street 1:705 E MAIN AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4525
Practice Address - Country:US
Practice Address - Phone:701-502-4669
Practice Address - Fax:833-490-3699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-23
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care