1720465834 NPI number — PHOENIX HOME CARE ILLINOIS, LLC

Table of content: (NPI 1720465834)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720465834 NPI number — PHOENIX HOME CARE ILLINOIS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHOENIX HOME CARE ILLINOIS, 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:
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:
1720465834
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/03/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3450 N. ROCK RD
Provider Second Line Business Mailing Address:
#213 ATTN DEBRA MULLEN
Provider Business Mailing Address City Name:
WICHITA
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67226
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
316-688-5511
Provider Business Mailing Address Fax Number:
314-205-3031

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
784 WALL ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
O FALLON
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62269-1959
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-205-3020
Provider Business Practice Location Address Fax Number:
314-205-3031
Provider Enumeration Date:
04/28/2015

Additional Information

Authorized Official

Authorized Official Last Name:
HERMAN
Authorized Official First Name:
GEORGE
Authorized Official Middle Name:
SCOTT
Authorized Official Title or Position:
PRESIDENT/SECRETARY
Authorized Official Telephone Number:
512-632-7156

Provider Taxonomy Codes

  • Taxonomy code: 251J00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 266501303 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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