Healthcare Provider Details

I. General information

NPI: 1366382889
Provider Name (Legal Business Name): PHOENIX PLACE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2026
Last Update Date: 04/01/2026
Certification Date: 04/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 HARLENE DR
SIKESTON MO
63801-8317
US

IV. Provider business mailing address

50 HARLENE DR
SIKESTON MO
63801-8317
US

V. Phone/Fax

Practice location:
  • Phone: 573-421-2450
  • Fax:
Mailing address:
  • Phone: 573-421-2450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: PAULA FARMER
Title or Position: MEMBER
Credential: BSW
Phone: 573-421-2450