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General NPI Number Information
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NPI Number | 1376221713
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Entity Type | Organization
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Legal Business Name | PHENOMENAL CARE SERVICES LLC
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Dates
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Enumeration Date | 07/06/2023
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Last Update Date | 07/06/2023
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Provider Practice Location Address
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Address Line | 3040 WICKER ST NE
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City | CANTON
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State | OH
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Zip | 44721-2298
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Country | US
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Telephone | 234-521-1318
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 44
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City | MIDDLEBRANCH
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State | OH
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Zip | 44652-0044
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Country | US
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Telephone | 234-521-1318
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MR. DARRYL WAYNE PETERSON II
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Credential |
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Telephone | 234-521-1318
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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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 | 347C00000X
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Taxonomy Name | Private Vehicle
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License Number |
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License Number State |
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