MEDICARE: FRONTLINE INTERVENTION SOLUTION TODAY-ORGANIZATION LLC LIMITED LIABILI

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	324500000X	Substance Abuse Rehabilitation Facility	LAC264	KS

General Provider Information

NPI Number	:	1740538982
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FRONTLINE INTERVENTION SOLUTION TODAY-ORGANIZATION LLC LIMITED LIABILI

Provider Business Mailing Address
First Line	:	3211 N 38TH ST
Second Line	:
City	:	KANSAS CITY
State	:	KS
Zip	:	66104-3726
Country	:	US
Telephone Number	:	913-999-5874
Fax Number	:	913-999-5874

Provider Business Practice Location Address
First Line	:	3211 N 38TH ST
Second Line	:
City	:	KANSAS CITY
State	:	KS
Zip	:	66104-3726
Country	:	US
Telephone Number	:	913-999-5874
Fax Number	:	913-999-5874

Authorized Official
Title or Position	:	C.E.O
Name	:	MR. JIMMIE C. PHOENIX SR.
Credential	:	LAC ADDICTION COUNS
Telephone Number	:	913-999-5874

Provider Enumeration Date	:	08/20/2012
Last Update Date	:	08/20/2012

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