Healthcare Provider Details

I. General information

NPI: 1174691646
Provider Name (Legal Business Name): SOUTHERN HOME ASSISTED LIVING,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3854 HIGHWAY 2
GRACEVILLE FL
32440-7406
US

IV. Provider business mailing address

3854 HWY 2
GRACEVILLE FL
32440
US

V. Phone/Fax

Practice location:
  • Phone: 850-263-7999
  • Fax: 850-263-6555
Mailing address:
  • Phone: 850-263-7999
  • Fax: 850-263-6555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License NumberAL10417
License Number StateFL

VIII. Authorized Official

Name: MRS. KAREN CECILE STOE
Title or Position: PRESIDENT
Credential: RN
Phone: 850-263-7999