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General NPI Number Information
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NPI Number | 1053495515
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Entity Type | Organization
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Legal Business Name | PHOENIX SPECIALTYCARE, LLC
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Dates
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Enumeration Date | 10/24/2006
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Last Update Date | 10/18/2007
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Provider Practice Location Address
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Address Line | 199 INTERSTATE DR SUITE D
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City | RICHLAND
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State | MS
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Zip | 39218-4428
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Country | US
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Telephone | 601-932-3815
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Fax |
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Provider Business Mailing Address
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Address Line | 199 INTERSTATE DR SUITE D
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City | RICHLAND
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State | MS
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Zip | 39218-4428
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Country | US
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Telephone | 601-932-3815
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | MR. ROLAND B WALL III
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Credential |
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Telephone | 601-932-3815
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332BP3500X
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Taxonomy Name | Parenteral & Enteral Nutrition Supplies (DME)
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License Number |
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License Number State |
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