Provider Demographics
NPI:1871909093
Name:SOVEREIGN PHOENIX
Entity type:Organization
Organization Name:SOVEREIGN PHOENIX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TYRONE
Authorized Official - Middle Name:
Authorized Official - Last Name:BARNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-303-0967
Mailing Address - Street 1:15 CUTTERMILL RD
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-3252
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 CUTTERMILL RD
Practice Address - Street 2:
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-3252
Practice Address - Country:US
Practice Address - Phone:516-303-0967
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-08
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Multi-Specialty