Provider Demographics
NPI:1336437623
Name:PHOENIX HOME CARE, LLC
Entity Type:Organization
Organization Name:PHOENIX HOME CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:HERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-688-5511
Mailing Address - Street 1:3450 N. ROCK RD.
Mailing Address - Street 2:#213 ATTN: DEBRA MULLEN
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226
Mailing Address - Country:US
Mailing Address - Phone:316-688-5511
Mailing Address - Fax:
Practice Address - Street 1:1839 E INDEPENDENCE ST STE K
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-3753
Practice Address - Country:US
Practice Address - Phone:417-881-7442
Practice Address - Fax:417-889-7442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-20
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO26-7629OtherMEDICARE PTAN
MO26-7629OtherMEDICARE PTAN