Healthcare Provider Details

I. General information

NPI: 1205877073
Provider Name (Legal Business Name): SOUTHERNCARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 05/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 NE WINDSOR DR
LEES SUMMIT MO
64086-5594
US

IV. Provider business mailing address

655 BRAWLEY SCHOOL RD SUITE 200
MOORESVILLE NC
28117-9125
US

V. Phone/Fax

Practice location:
  • Phone: 816-524-3663
  • Fax: 816-524-3669
Mailing address:
  • Phone: 704-664-2876
  • Fax: 704-664-1306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number1211H0
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code251G00000X
TaxonomyCommunity Based Hospice Care Agency
License Number121-11HO
License Number StateMO

VIII. Authorized Official

Name: JESSICA KLEBERG
Title or Position: VP OF LEGAL AFFAIRS
Credential:
Phone: 704-664-2876