Provider Demographics
NPI:1366493066
Name:PHOENIX HEALTHCARE LLC
Entity Type:Organization
Organization Name:PHOENIX HEALTHCARE LLC
Other - Org Name:TRAYLOR NURSING HOME, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-863-3500
Mailing Address - Street 1:PO BOX 467
Mailing Address - Street 2:1235 YANCEY STREET
Mailing Address - City:ROANOKE
Mailing Address - State:AL
Mailing Address - Zip Code:36274-0467
Mailing Address - Country:US
Mailing Address - Phone:334-863-3500
Mailing Address - Fax:334-863-3531
Practice Address - Street 1:1235 YANCEY ST
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:AL
Practice Address - Zip Code:36274-2141
Practice Address - Country:US
Practice Address - Phone:334-863-3500
Practice Address - Fax:334-863-3531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL10641314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL4752240SMedicaid
AL021561OtherBLUE CROSS BLUE SHIELD
AL4752240SMedicaid
AL015126Medicare Oscar/Certification