Provider Demographics
NPI:1639290596
Name:PHOENIX PREFERRED CARE, INC.
Entity Type:Organization
Organization Name:PHOENIX PREFERRED CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:HAMM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-451-9379
Mailing Address - Street 1:PO BOX 2
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42502-0002
Mailing Address - Country:US
Mailing Address - Phone:606-451-9379
Mailing Address - Fax:606-451-8149
Practice Address - Street 1:201 E MOUNT VERNON ST
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501-1412
Practice Address - Country:US
Practice Address - Phone:606-451-9379
Practice Address - Fax:606-451-8149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY069364251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY29101847OtherIMPACT PLUS PROVIDER ID
KY29201845OtherIMPACT PLUS PROVIDER ID