Healthcare Provider Details

I. General information

NPI: 1467003533
Provider Name (Legal Business Name): SOUTHERN CAREGIVERS OF STAR CITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1771 GREEN HILLS RD
STAR CITY AR
71667-8304
US

IV. Provider business mailing address

709 COVENANT PL
SEARCY AR
72143-6746
US

V. Phone/Fax

Practice location:
  • Phone: 870-308-5132
  • Fax:
Mailing address:
  • Phone: 870-308-5132
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: BLAKE WATSON
Title or Position: OWNER
Credential:
Phone: 870-904-4277