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	131	LA
2	251G00000X	Community Based Hospice Care Agency	257	LA

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	:	1740229178
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERNCARE, INC.

Provider Business Mailing Address
First Line	:	PO BOX 4060
Second Line	:
City	:	MOORESVILLE
State	:	NC
Zip	:	28117-4060
Country	:	US
Telephone Number	:	704-662-0416
Fax Number	:	704-664-1306

Provider Business Practice Location Address
First Line	:	590 BOARDWALK BLVD
Second Line	:	SUITE BO-590
City	:	BOSSIER CITY
State	:	LA
Zip	:	71111-4384
Country	:	US
Telephone Number	:	318-227-9160
Fax Number	:	318-227-9781

Authorized Official
Title or Position	:	VP OF LICENSURE
Name	:	MR. JANET COMBS
Credential	:
Telephone Number	:	704-662-1761

Provider Enumeration Date	:	06/04/2006
Last Update Date	:	01/11/2023

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Directions to “SOUTHERNCARE, INC. ” Practice Location

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