MEDICARE: SOUTHERNCARE, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251G00000X	Community Based Hospice Care Agency	SATELLITE OFFICE	IN
2	251G00000X	Community Based Hospice Care Agency	14-002998-1	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1710927298
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERNCARE, INC.

Provider Business Mailing Address
First Line	:	655 BRAWLEY SCHOOL RD
Second Line	:	SUITE 200
City	:	MOORESVILLE
State	:	NC
Zip	:	28117-9125
Country	:	US
Telephone Number	:	704-664-2876
Fax Number	:	704-662-1306

Provider Business Practice Location Address
First Line	:	1923 S LIBERTY DR
Second Line	:
City	:	BLOOMINGTON
State	:	IN
Zip	:	47403-5146
Country	:	US
Telephone Number	:	812-334-8343
Fax Number	:	812-334-8949

Authorized Official
Title or Position	:	VP OF LEGAL AFFAIRS
Name	:	JESSICA KLEBERG
Credential	:
Telephone Number	:	704-664-2876

Provider Enumeration Date	:	06/07/2006
Last Update Date	:	05/16/2016

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Directions to “SOUTHERNCARE, INC. ” Practice Location

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