Provider Demographics
NPI:1730288507
Name:PHOENIX HEALTHCARE, LLC
Entity Type:Organization
Organization Name:PHOENIX HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROLAND
Authorized Official - Middle Name:B
Authorized Official - Last Name:WALL
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:601-932-3397
Mailing Address - Street 1:199 INTERSTATE DR
Mailing Address - Street 2:SUITE U
Mailing Address - City:RICHLAND
Mailing Address - State:MS
Mailing Address - Zip Code:39218-4428
Mailing Address - Country:US
Mailing Address - Phone:601-932-3397
Mailing Address - Fax:601-932-3398
Practice Address - Street 1:199 INTERSTATE DR
Practice Address - Street 2:SUITE U
Practice Address - City:RICHLAND
Practice Address - State:MS
Practice Address - Zip Code:39218-4428
Practice Address - Country:US
Practice Address - Phone:601-932-3397
Practice Address - Fax:601-932-3398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06824216Medicaid
MS5240480001Medicare NSC