Healthcare Provider Details

I. General information

NPI: 1962634337
Provider Name (Legal Business Name): PHOENIX HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2009
Last Update Date: 08/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 SOUTH LAUREL STREET
SUMMIT MS
39666-9487
US

IV. Provider business mailing address

199 INTERSTATE DR STE C
RICHLAND MS
39218-4428
US

V. Phone/Fax

Practice location:
  • Phone: 601-276-3132
  • Fax: 601-276-3179
Mailing address:
  • Phone: 601-932-3397
  • Fax: 601-932-3398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. ROLAND B WALL III
Title or Position: MANAGER
Credential:
Phone: 601-932-3397