Provider Demographics
NPI:1518206226
Name:PHOENIX HOME CARE, INC.
Entity Type:Organization
Organization Name:PHOENIX HOME CARE, INC.
Other - Org Name:PHOENIX HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:DEE
Authorized Official - Last Name:KELTNER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:417-881-7442
Mailing Address - Street 1:3033 S KANSAS EXPY
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5969
Mailing Address - Country:US
Mailing Address - Phone:417-881-7442
Mailing Address - Fax:417-889-7442
Practice Address - Street 1:515A BEE CREEK RD
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-7734
Practice Address - Country:US
Practice Address - Phone:417-881-7442
Practice Address - Fax:417-889-7442
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHOENIX HOME CARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-02-01
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO26-7649Medicare UPIN