MEDICARE: PHOENIX HEALTHCARE 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	314000000X	Skilled Nursing Facility	10641	AL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	021561	OTHER	AL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1366493066
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENIX HEALTHCARE LLC

Provider Business Mailing Address
First Line	:	PO BOX 467
Second Line	:	1235 YANCEY STREET
City	:	ROANOKE
State	:	AL
Zip	:	36274-0467
Country	:	US
Telephone Number	:	334-863-3500
Fax Number	:	334-863-3531

Provider Business Practice Location Address
First Line	:	1235 YANCEY ST
Second Line	:
City	:	ROANOKE
State	:	AL
Zip	:	36274-2141
Country	:	US
Telephone Number	:	334-863-3500
Fax Number	:	334-863-3531

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. RONALD TRAYLOR
Credential	:
Telephone Number	:	334-863-3500

Provider Enumeration Date	:	05/15/2006
Last Update Date	:	12/20/2011

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Directions to “PHOENIX HEALTHCARE LLC ” Practice Location

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