1114965688 NPI number — SOUTHERNCARE, INC.

Table of content: (NPI 1114965688)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114965688 NPI number — SOUTHERNCARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERNCARE, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114965688
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/11/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
655 BRAWLEY SCHOOL RD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
MOORESVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28117-9125
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-664-2876
Provider Business Mailing Address Fax Number:
704-664-1306

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1911 WEST CENTER AVENUE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
PORTAGE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49024-5367
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-342-9308
Provider Business Practice Location Address Fax Number:
269-342-9462
Provider Enumeration Date:
06/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
COMBS
Authorized Official First Name:
JANET
Authorized Official Middle Name:
Authorized Official Title or Position:
VP OF LICENSURE
Authorized Official Telephone Number:
704-662-1761

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X , with the licence number:  393525 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251G00000X , with the licence number: 1041000077 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4610877 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 15/4610877 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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