Healthcare Provider Details

I. General information

NPI: 1063715902
Provider Name (Legal Business Name): SOUTHERN HOME CARE SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2010
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1399 BIG A RD
TOCCOA GA
30577-6030
US

IV. Provider business mailing address

805 N WHITTINGTON PKWY
LOUISVILLE KY
40222-7101
US

V. Phone/Fax

Practice location:
  • Phone: 706-282-0060
  • Fax:
Mailing address:
  • Phone: 800-866-0860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier000552538BE
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer

VIII. Authorized Official

Name: MR. TIMOTHY WHOBREY
Title or Position: PROVIDER ENROLLMENT
Credential:
Phone: 502-630-7249