1609493725 NPI number — PHOENIX SQUARED, LLC

Table of content: (NPI 1609493725)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609493725 NPI number — PHOENIX SQUARED, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHOENIX SQUARED, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609493725
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
240 CHEROKEE ST NE STE 302
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARIETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30060-1628
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-354-0102
Provider Business Mailing Address Fax Number:
678-354-0014

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
240 CHEROKEE ST NE STE 302
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARIETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30060-1628
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-354-0102
Provider Business Practice Location Address Fax Number:
678-354-0014
Provider Enumeration Date:
07/06/2020

Additional Information

Authorized Official

Authorized Official Last Name:
ENIX
Authorized Official First Name:
DALE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
678-354-0102

Provider Taxonomy Codes

  • Taxonomy code: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 033-R-0092 . This is a "DEPARTMENT OF COMMUNITY HEALTH PRIVATE HOME CARE PROVIDER PERMIT" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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