Provider Demographics
NPI:1750894366
Name:PHOENIX HOME CARE INC
Entity type:Organization
Organization Name:PHOENIX HOME CARE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:ALEX
Authorized Official - Last Name:MELUGIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-688-5511
Mailing Address - Street 1:3033 S KANSAS EXPY
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5969
Mailing Address - Country:US
Mailing Address - Phone:417-881-7442
Mailing Address - Fax:417-889-7442
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?:Yes
Parent Organization LBN:PHOENIX HOME CARE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-11-06
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO267629251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO266501303Medicaid