Provider Demographics
NPI:1053495515
Name:PHOENIX SPECIALTYCARE, LLC
Entity Type:Organization
Organization Name:PHOENIX SPECIALTYCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROLAND
Authorized Official - Middle Name:B
Authorized Official - Last Name:WALL
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:601-932-3815
Mailing Address - Street 1:199 INTERSTATE DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:RICHLAND
Mailing Address - State:MS
Mailing Address - Zip Code:39218-4428
Mailing Address - Country:US
Mailing Address - Phone:601-932-3815
Mailing Address - Fax:
Practice Address - Street 1:199 INTERSTATE DR
Practice Address - Street 2:SUITE D
Practice Address - City:RICHLAND
Practice Address - State:MS
Practice Address - Zip Code:39218-4428
Practice Address - Country:US
Practice Address - Phone:601-932-3815
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition