Provider Demographics
NPI:1720465834
Name:PHOENIX HOME CARE ILLINOIS, LLC
Entity Type:Organization
Organization Name:PHOENIX HOME CARE ILLINOIS, 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:512-632-7156
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:314-205-3031
Practice Address - Street 1:784 WALL ST
Practice Address - Street 2:SUITE B
Practice Address - City:O FALLON
Practice Address - State:IL
Practice Address - Zip Code:62269-1959
Practice Address - Country:US
Practice Address - Phone:314-205-3020
Practice Address - Fax:314-205-3031
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHOENIX HOME CARE, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-28
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO266501303Medicaid