Provider Demographics
NPI:1366888059
Name:PHOENIX HOME CARE, LLC
Entity type:Organization
Organization Name:PHOENIX HOME CARE, LLC
Other - Org Name:<UNAVAIL>
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:417-881-7442
Mailing Address - Street 1:3450 N. ROCK RD.
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-1352
Mailing Address - Country:US
Mailing Address - Phone:316-688-5511
Mailing Address - Fax:
Practice Address - Street 1:500 BROADWAY
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65101-1610
Practice Address - Country:US
Practice Address - Phone:573-635-3900
Practice Address - Fax:573-635-6297
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHOENIX HOME CARE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-05-21
Last Update Date:2021-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO853-HH251E00000X
251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO26-7597Medicare UPIN