Healthcare Provider Details

I. General information

NPI: 1962793547
Provider Name (Legal Business Name): PHOENIX HOME CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2011
Last Update Date: 12/10/2021
Certification Date: 12/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1839 E INDEPENDENCE ST STE K
SPRINGFIELD MO
65804-3753
US

IV. Provider business mailing address

3450 N. ROCK RD. #213 ATTN: DEBRA MULLEN
WITCHITA KS
67226-1352
US

V. Phone/Fax

Practice location:
  • Phone: 417-818-3565
  • Fax:
Mailing address:
  • Phone: 316-688-5511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number State

VIII. Authorized Official

Name: GEORGE SCOTT HERMAN
Title or Position: PRESIDENT AND SECRETARY
Credential:
Phone: 903-390-4040