Healthcare Provider Details

I. General information

NPI: 1922574391
Provider Name (Legal Business Name): THE PHOENIX OVERSIGHT AND CONSULTING, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2018
Last Update Date: 10/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7746 RANNELLS AVE
SAINT LOUIS MO
63143-1823
US

IV. Provider business mailing address

5856 S LOWELL BLVD # 32-403
LITTLETON CO
80123-7915
US

V. Phone/Fax

Practice location:
  • Phone: 636-226-4159
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN KIDD
Title or Position: OWNER/CHIEF OPERATING OFFICER
Credential: CNIM
Phone: 217-821-0759