Provider Demographics
NPI:1376221713
Name:PHENOMENAL CARE SERVICES LLC
Entity Type:Organization
Organization Name:PHENOMENAL CARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:II
Authorized Official - Credentials:
Authorized Official - Phone:234-521-1318
Mailing Address - Street 1:PO BOX 44
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBRANCH
Mailing Address - State:OH
Mailing Address - Zip Code:44652-0044
Mailing Address - Country:US
Mailing Address - Phone:234-521-1318
Mailing Address - Fax:
Practice Address - Street 1:3040 WICKER ST NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44721-2298
Practice Address - Country:US
Practice Address - Phone:234-521-1318
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
No251C00000XAgenciesDay Training, Developmentally Disabled Services