| Organization Name: | PHOENIX SPECIALTYCARE, LLC |
| NPI Number: | 1053495515 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | ROLAND B WALL (MANAGER) |
| Mailing Address: | 199 Interstate Dr Suite D Richland |
| State: | MS US |
| Postal Code: | 392184428 |
| Phone Number: | 6019323815 |
| Fax Number: | |
| NPI Enumeration Date: | 10/24/2006 |
| NPI Last Update Date: | 10/18/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 332BP3500X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Suppliers |
| Taxonomy Classification: | Durable Medical Equipment & Medical Supplies |
| Taxonomy Specialization: | Parenteral & Enteral Nutrition |
| Taxonomy Definition: | |