MEDICARE: PHOENIX HOME CARE, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	26-7629	OTHER	MO	MEDICARE PTAN

General Provider Information

NPI Number	:	1336437623
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENIX HOME CARE, LLC

Provider Business Mailing Address
First Line	:	3450 N. ROCK RD.
Second Line	:	#213 ATTN: DEBRA MULLEN
City	:	WICHITA
State	:	KS
Zip	:	67226
Country	:	US
Telephone Number	:	316-688-5511
Fax Number	:

Provider Business Practice Location Address
First Line	:	1839 E INDEPENDENCE ST STE K
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65804-3753
Country	:	US
Telephone Number	:	417-881-7442
Fax Number	:	417-889-7442

Authorized Official
Title or Position	:	PRESIDENT & SECRETARY
Name	:	GEORGE SCOTT HERMAN
Credential	:
Telephone Number	:	316-688-5511

Provider Enumeration Date	:	07/20/2011
Last Update Date	:	12/10/2021

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