| Name: | Phoenix Healthcare, LLC |
| Jurisdiction: | Alabama |
| Legal type: | Domestic Limited Liability Company |
| Status: | Dissolved |
| Date of registration: | 04 Aug 2004 (20 years ago) (Companies founded in August 2004) |
| Date of dissolution: | 03 Jan 2017 |
| Entity Number: | 000-453-840 |
| Register Number: | 000453840 |
| ZIP code: | 36274 (Companies in Randolph, 36274) |
| County: | Randolph |
| Place of Formation: | Randolph County |
| Principal Address: | ROANOKE, AL |
| Registered Office Street Address: | 1235 YANCEY STROANOKE, AL 36274 |
Activities
OPERATE A SKILLED NURSING FACILITY
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1366493066 | 2006-05-15 | 2011-12-20 | PO BOX 467, 1235 YANCEY STREET, ROANOKE, AL, 362740467, US | 1235 YANCEY ST, ROANOKE, AL, 362742141, US | |||||||||||||||||||||||||||||||
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| Phone | +1 334-863-3500 |
| Fax | 3348633531 |
Authorized person
| Name | MR. RONALD TRAYLOR |
| Role | ADMINISTRATOR |
| Phone | 3348633500 |
Taxonomy
| Taxonomy Code | 314000000X - Skilled Nursing Facility |
| License Number | 10641 |
| State | AL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 4752240S |
| State | AL |
| Issuer | BLUE CROSS BLUE SHIELD |
| Number | 021561 |
| State | AL |
| Name | Role |
|---|---|
| TRAYLOR, RONALD | Agent |
| Name | Role | Address |
|---|---|---|
| TRAYLOR, RONALD | Member | No data |
| TRAYLOR, SUSAN | Member | No data |
| AGUILAR, DENISE T | Member | No data |
| TRAYLOR, ASHLEY KEVIN | Member | 207 CAUTHEN CIRCLEROANOKE, AL 36274 |
| TRAYLOR, JONATHAN MARCUS | Member | 219 SOUTH 8TH STREETOPELIKA, AL 36801-2126 |
| TRAYLOR, KRISTINA RENEE | Member | No data |
Date of last update: 13 Aug 2024
Sources: Alabama Secretary of State
