Healthcare Provider Details

I. General information

NPI: 1366764185
Provider Name (Legal Business Name): SOUTHCARE MEDICAL & HOMECARE SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2010
Last Update Date: 03/10/2023
Certification Date: 03/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1303 E UNION ST STE A
VIENNA GA
31092-7540
US

IV. Provider business mailing address

1150 INDUSTRIAL DR SUITE 142
VIENNA GA
31092-1333
US

V. Phone/Fax

Practice location:
  • Phone: 404-844-9975
  • Fax: 888-687-4829
Mailing address:
  • Phone: 404-552-4361
  • Fax: 229-888-3558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number046-R-0644
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MR. GEORGE ECHEBELEM
Title or Position: OPERATING MANAGER
Credential:
Phone: 404-844-9975