Healthcare Provider Details

I. General information

NPI: 1538156278
Provider Name (Legal Business Name): SOUTHERN HOME RESPIRATORY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 10/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1386 ROSS CLARK CIR
DOTHAN AL
36301-4117
US

IV. Provider business mailing address

1386 ROSS CLARK CIR
DOTHAN AL
36301-4117
US

V. Phone/Fax

Practice location:
  • Phone: 334-699-2630
  • Fax: 334-699-2639
Mailing address:
  • Phone: 334-699-2630
  • Fax: 334-699-2630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number117
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number90265
License Number StateAL

VIII. Authorized Official

Name: MR. KENNEY DURIEL AUSTIN
Title or Position: CO-OWNER/PRESIDENT (CORP)
Credential: CRRT
Phone: 334-699-2630