Provider Demographics
NPI:1770916892
Name:PHOENIX MEDICAL SUPPLIES LLC
Entity type:Organization
Organization Name:PHOENIX MEDICAL SUPPLIES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:NIELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:262-955-8911
Mailing Address - Street 1:512 OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-5573
Mailing Address - Country:US
Mailing Address - Phone:262-955-8911
Mailing Address - Fax:
Practice Address - Street 1:512 OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53186-5573
Practice Address - Country:US
Practice Address - Phone:262-955-8911
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-13
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI456-1028557037-02332BP3500X, 332BX2000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies