Provider Demographics
NPI:1003382680
Name:PHOENIX HOME CARE, LLC
Entity Type:Organization
Organization Name:PHOENIX HOME CARE, LLC
Other - Org Name:PHOENIX HOME CARE AND HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:HERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-838-3000
Mailing Address - Street 1:3450 N. ROCK RD.
Mailing Address - Street 2:#213, ATTN: DEBRA MULLEN
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-1352
Mailing Address - Country:US
Mailing Address - Phone:316-688-5511
Mailing Address - Fax:417-889-7442
Practice Address - Street 1:3033 S KANSAS EXPY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5969
Practice Address - Country:US
Practice Address - Phone:417-881-7442
Practice Address - Fax:417-889-7442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-22
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO8500Medicaid