Healthcare Provider Details

I. General information

NPI: 1538970827
Provider Name (Legal Business Name): PHOENIX HOME CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/15/2025
Last Update Date: 02/03/2025
Certification Date: 02/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12334 QUARTERBACK CT
BOWIE MD
20720-4396
US

IV. Provider business mailing address

12334 QUARTERBACK CT
BOWIE MD
20720-4396
US

V. Phone/Fax

Practice location:
  • Phone: 609-705-2561
  • Fax:
Mailing address:
  • Phone: 609-705-2561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State

VIII. Authorized Official

Name: KISH BOLDEN
Title or Position: DIRECTOR
Credential:
Phone: 609-705-2561