Organization
PHOENIX SPECIALTYCARE, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. ROLAND B WALL III (MANAGER)
(601) 932-3815
Entity
Organization
Contact information
Practice address
199 INTERSTATE DR, SUITE D, RICHLAND, MS 39218-4428
(601) 932-3815
Mailing address
199 INTERSTATE DR, SUITE D, RICHLAND, MS 39218-4428
(601) 932-3815
Taxonomy
Speciality
Code
Description
License number
State
332BP3500X
Parenteral & Enteral Nutrition Supplies (DME)
Primary
—
—
Other
Enumeration date
10/24/2006
Last updated
10/18/2007
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