Healthcare Provider Details

I. General information

NPI: 1578587317
Provider Name (Legal Business Name): SOUTHERN HOME RESPIRATORY OF FL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 10/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5426 CLIFFF ST
GRACEVILLE FL
32440-1734
US

IV. Provider business mailing address

5426 CLIFFF ST
GRACEVILLE FL
32440-1734
US

V. Phone/Fax

Practice location:
  • Phone: 850-263-3800
  • Fax: 850-263-5600
Mailing address:
  • Phone: 850-263-3800
  • Fax: 850-263-5600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number1312609
License Number StateFL

VIII. Authorized Official

Name: MRS. GLENDA J HOWARD
Title or Position: CO OWNER SECRETARY TREASURER
Credential:
Phone: 850-263-3800