MEDICARE: PHOENIX HOME CARE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility		MO

General Provider Information

NPI Number	:	1003382680
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENIX HOME CARE, LLC

Provider Business Mailing Address
First Line	:	3450 N. ROCK RD.
Second Line	:	#213, ATTN: DEBRA MULLEN
City	:	WICHITA
State	:	KS
Zip	:	67226-1352
Country	:	US
Telephone Number	:	316-688-5511
Fax Number	:	417-889-7442

Provider Business Practice Location Address
First Line	:	3033 S KANSAS EXPY
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65807-5969
Country	:	US
Telephone Number	:	417-881-7442
Fax Number	:	417-889-7442

Authorized Official
Title or Position	:	PRESIDENT & SECRETARY
Name	:	GEORGE SCOTT HERMAN
Credential	:
Telephone Number	:	417-838-3000

Provider Enumeration Date	:	10/22/2018
Last Update Date	:	12/13/2021

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