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General NPI Number Information
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NPI Number | 1124825666
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Entity Type | Organization
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Legal Business Name | PHOENIX INDEPENDENT LIVING INC
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Dates
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Enumeration Date | 03/03/2025
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Last Update Date | 03/03/2025
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Provider Practice Location Address
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Address Line | 2810 53RD AVE # B
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City | GULFPORT
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State | MS
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Zip | 39501-5644
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Country | US
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Telephone | 601-325-8121
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Fax |
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Provider Business Mailing Address
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Address Line | 2810 53RD AVE # B
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City | GULFPORT
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State | MS
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Zip | 39501-5644
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Country | US
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Telephone | 601-325-8121
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | JUSTIN HOLCOMB
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Credential |
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Telephone | 601-325-8121
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 246RM2200X
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Taxonomy Name | Medical Laboratory Technician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 343900000X
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Taxonomy Name | Non-emergency Medical Transport (VAN)
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number |
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License Number State |
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