MEDICARE: PHOENIX HOME CARE, INC.

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

General Provider Information

NPI Number	:	1689903890
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHOENIX HOME CARE, INC.

Provider Business Mailing Address
First Line	:	1543 LAKELAND HILLS BLVD
Second Line	:	SUITE 16
City	:	LAKELAND
State	:	FL
Zip	:	33805-3246
Country	:	US
Telephone Number	:	863-686-2005
Fax Number	:	863-686-2011

Provider Business Practice Location Address
First Line	:	1543 LAKELAND HILLS BLVD
Second Line	:	SUITE 16
City	:	LAKELAND
State	:	FL
Zip	:	33805-3246
Country	:	US
Telephone Number	:	863-686-2005
Fax Number	:	863-686-2011

Authorized Official
Title or Position	:	CEO PRESIDENT
Name	:	MR. ROBERT P GAMMONS
Credential	:
Telephone Number	:	321-286-7916

Provider Enumeration Date	:	12/17/2009
Last Update Date	:	07/08/2014

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