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PHOENIX RESIDENCE, INC.
NPI 1457458812
Intermediate Care Facility, Intellectual Disabilities in White Bear Lake, MN

Active since September 20, 2006CLIA 24D1041851 · Waiver
2168 12TH STREET, WHITE BEAR LAKE, MN 55110(651) 653-3713(651) 653-5784 Get Directions Write a Review

NPPES record last updated: July 1, 2008. Verified against the NPPES registry weekly; last sync: August 16, 2026.

About Phoenix Residence, Inc. NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

PHOENIX RESIDENCE, INC. (NPI 1457458812) is a healthcare organization registered as an intermediate care facility, intellectual disabilities in White Bear Lake, Minnesota and active in the NPI registry since September 2006. The organization holds a CLIA Waiver certificate valid through April 11, 2028 and lists Darlene M Scott, President/ceo, as its authorized official.

NPPES Registry Identity

NPI1457458812
Entity TypeOrganization
Primary Taxonomy315P00000X
Legal Business NamePHOENIX RESIDENCE, INC.
Location Address2168 12TH STREETWhite Bear Lake, MN 55110
Mailing Address330 Marie Ave EWest St Paul, MN 55118-4011 · (651) 227-7655 · Fax (651) 227-6847
Phone(651) 653-3713
Fax(651) 653-5784
Organization SubpartNo
Authorized OfficialDarlene M ScottPresident/ceo · (651) 227-7655
Enumeration DateSeptember 20, 2006
Last NPPES UpdateJuly 1, 2008
✔ NPI 1457458812 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses

★ Primary SpecialtyIntermediate Care Facility, Intellectual DisabilitiesNursing & Custodial Care Facilities
Taxonomy Code315P00000X
License✔ Licensed in MN · 1032511 1 RS
Definition
An intermediate care facility providing services for individuals with intellectual disabilities.
2168 12TH STREET, White Bear Lake, MN 55110
Open in Google Maps ↗

Other Identifiers 1

Medicaid714417200MN

CLIA Laboratory Certificates CMS CLIA

Laboratory certificates issued under the Clinical Laboratory Improvement Amendments (CLIA) program, which sets federal quality standards for human laboratory testing in the United States. There is no official CMS crosswalk between CLIA and NPI numbers; these certificates are associated with this NPI by matching facility names, locations and phone numbers in the CMS CLIA registry.

Certificate of Waiver 24D1041851

Phoenix Residence Caswell · White Bear Lake, MN
Active · expires Apr 11, 2028
CLIA Number24D1041851
Laboratory TypeIntermediate Care Facility For Mentally Retarded
Certificate Effective DateApril 12, 2026
Certificate Expiration DateApril 11, 2028
Laboratory DirectorKimberly E. Human
Laboratory Phone(651) 653-3713
Laboratory LocationPhoenix Residence Caswell2168 12th Street, White Bear Lake, MN 55110
CLIA data matches this NPI record on: Address Name Phone
This certificate is issued to a laboratory to perform only waived tests.

Frequently Asked Questions NPPES & CMS

Common questions about this NPI record, answered from the official NPPES registry and CMS datasets shown on this page.

What is Phoenix Residence, Inc.'s NPI number?

The NPI number for Phoenix Residence, Inc. is 1457458812. It was assigned to this organization in the NPPES registry on September 20, 2006.

Where is Phoenix Residence, Inc. located?

Phoenix Residence, Inc. is located at 2168 12th Street, White Bear Lake, MN 55110. The listed phone number is (651) 653-3713.

What is Phoenix Residence, Inc.'s specialty?

The primary specialty registered for this NPI is Intermediate Care Facility, Intellectual Disabilities with taxonomy code 315P00000X.

Does Phoenix Residence, Inc. hold a CLIA laboratory certificate?

Yes. A Certificate of Waiver (number 24D1041851) is associated with this NPI, valid through April 11, 2028. CLIA certificates authorize laboratory testing under the federal Clinical Laboratory Improvement Amendments program.

When was this NPI record last updated?

The NPPES record for Phoenix Residence, Inc. was last updated on July 1, 2008. NPI Profile syncs weekly with the NPPES registry data releases published by CMS. This NPI record was last updated 18 years ago. If this record has changed at CMS more recently, you can request an on-demand re-check against the live CMS registry, directly from this page.