NPIMap

Organization Active NPI

PHCS IV, Inc.

  • Home Health Agency
  • Tyler, TX
National Provider Identifier
1508025396
Registry record updated Nov 17, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Home Health AgencyTaxonomy code 251E00000X
Legal business name
PHCS IV, INC.
Practice address
1021 E Southeast Loop 323 Ste 110B
Tyler, TX 75701-9656
Phone
(903) 526-0443
Fax
(469) 374-5420
NPI assigned
Jun 5, 2008
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 17, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mrs. Patricia A Henderson
Title
Administrator/President
Phone
(903) 526-0443

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Home Health Agency 251E00000X TX Primary

Addresses

Primary practice location

1021 E Southeast Loop 323 Ste 110B
Tyler, TX 75701-9656

Mailing address

1021 E Southeast Loop 323 Ste 110B
Tyler, TX 75701-9656
Phone (903) 526-0443

Other names 1

  • PREMIER HEALTHCARE SERVICES-LAKESIDE Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20090805000351 TX Part A Provider - Home Health Agency 2567515711 Practice locations: Tyler, TX

Home health agency certification: CCN 673137

Legal name
PHCS IV, INC.
Doing business as
PREMIER HEALTHCARE SERVICES-LAKESIDE
Certification status
Active
Provider type (POS)
Home health agency
Participating since
Mar 7, 2005
Last certification
Aug 27, 2020
Ownership / control type
Proprietary
Organization structure
CorporationProprietary
Incorporated
May 21, 2008 in TX
Enrollment address
1021 E Southeast Loop 323
Ste 110B
Tyler, TX 75701-9656
HHA Branch

Care Compare: Home health agency

Medicare Care Compare
Listed as
Premier Healthcare Services LakesideCCN 673137
Ownership
Proprietary
Certified
Mar 7, 2005
Medicare certification status
ActiveFrom the Provider of Services file
Services
Nursing, Medical social, Home health aide, Physical therapy, Speech pathology, Occupational therapy

National Provider Directory

National Provider Directory

Locations

707 N Palestine St
Athens, TX 75751
Phone (903) 672-1572

1021 E Southeast Loop 323
Ste 110B
Tyler, TX 75701
Phone (903) 526-0443

1324 S Beckham Ave
Ste 231B
Tyler, TX 75701

Ownership & related parties

All disclosed owners & managing parties 2

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Patricia Henderson Individual 5% Or Greater Direct Ownership InterestOwner Jun 1, 2008 50%
Corporate OfficerCeo Jun 1, 2008 50%
Corporate DirectorPresident Jun 1, 2008 50%
W-2 Managing EmployeeAdministrator Jun 1, 2008 50%
Franklin Hunter Individual 5% Or Greater Direct Ownership InterestOwner Jun 1, 2008 50%
Corporate OfficerCfo Jun 1, 2008 50%
Corporate DirectorVice President May 1, 2008 50%
W-2 Managing EmployeeAlternate Administrator Jun 1, 2008 50%

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1212624000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1605571200000",
    "number": "1508025396",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1021 E SOUTHEAST LOOP 323 STE 110B",
            "city": "TYLER",
            "state": "TX",
            "postal_code": "757019656",
            "telephone_number": "903-526-0443",
            "fax_number": "903-526-3482"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1021 E SOUTHEAST LOOP 323 STE 110B",
            "city": "TYLER",
            "state": "TX",
            "postal_code": "757019656",
            "telephone_number": "903-526-0443",
            "fax_number": "469-374-5420"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PHCS IV, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-06-05",
        "last_updated": "2020-11-17",
        "certification_date": "2020-11-10",
        "status": "A",
        "authorized_official_last_name": "HENDERSON",
        "authorized_official_first_name": "PATRICIA",
        "authorized_official_middle_name": "A",
        "authorized_official_title_or_position": "ADMINISTRATOR/PRESIDENT",
        "authorized_official_telephone_number": "903-526-0443",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "251E00000X",
            "taxonomy_group": "",
            "desc": "Home Health",
            "state": "TX",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PREMIER HEALTHCARE SERVICES-LAKESIDE",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "PREMIER HEALTHCARE SERVICES-LAKESIDE",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Tyler, TX

Sources for this page

Verify at the official NPI Registry.