Provider Demographics
NPI:1124825666
Name:PHOENIX INDEPENDENT LIVING INC
Entity type:Organization
Organization Name:PHOENIX INDEPENDENT LIVING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLCOMB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-325-8121
Mailing Address - Street 1:2810 53RD AVE # B
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-5644
Mailing Address - Country:US
Mailing Address - Phone:601-325-8121
Mailing Address - Fax:
Practice Address - Street 1:2810 53RD AVE # B
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-5644
Practice Address - Country:US
Practice Address - Phone:601-325-8121
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical LaboratoryGroup - Single Specialty
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)