Provider Demographics
NPI:1609493725
Name:PHOENIX SQUARED, LLC
Entity Type:Organization
Organization Name:PHOENIX SQUARED, LLC
Other - Org Name:COMFORT KEEPERS OF MARIETTA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:ENIX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-354-0102
Mailing Address - Street 1:240 CHEROKEE ST NE STE 302
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1628
Mailing Address - Country:US
Mailing Address - Phone:678-354-0102
Mailing Address - Fax:678-354-0014
Practice Address - Street 1:240 CHEROKEE ST NE STE 302
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1628
Practice Address - Country:US
Practice Address - Phone:678-354-0102
Practice Address - Fax:678-354-0014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-06
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA033-R-0092OtherDEPARTMENT OF COMMUNITY HEALTH PRIVATE HOME CARE PROVIDER PERMIT