Provider Demographics
NPI:1194570044
Name:PHENOMENAL HOME CARE LLC
Entity type:Organization
Organization Name:PHENOMENAL HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:CARTER
Authorized Official - Last Name:LYONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-955-7893
Mailing Address - Street 1:105 ONYX LN
Mailing Address - Street 2:
Mailing Address - City:KNIGHTDALE
Mailing Address - State:NC
Mailing Address - Zip Code:27545-7873
Mailing Address - Country:US
Mailing Address - Phone:252-955-7893
Mailing Address - Fax:
Practice Address - Street 1:105 ONYX LN
Practice Address - Street 2:
Practice Address - City:KNIGHTDALE
Practice Address - State:NC
Practice Address - Zip Code:27545-7873
Practice Address - Country:US
Practice Address - Phone:252-955-7893
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-23
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care