Provider Demographics
NPI:1326658477
Name:PHOENIX ENTERPRISE
Entity Type:Organization
Organization Name:PHOENIX ENTERPRISE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:NETHERTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-551-9988
Mailing Address - Street 1:300 W VINE ST STE 1408
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40507-1814
Mailing Address - Country:US
Mailing Address - Phone:859-900-2668
Mailing Address - Fax:
Practice Address - Street 1:3191 BEAUMONT CENTRE CIR STE 150
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40513-1830
Practice Address - Country:US
Practice Address - Phone:859-900-2668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY200414OtherKENTCKY STATE LICENSE
KY18D2188408OtherCLIA