Healthcare Provider Details

I. General information

NPI: 1174333884
Provider Name (Legal Business Name): SOUTHERN GRACE HOME CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2025
Last Update Date: 01/14/2025
Certification Date: 01/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 AMUR LN
HATTIESBURG MS
39402-5510
US

IV. Provider business mailing address

12 AMUR LN
HATTIESBURG MS
39402-5510
US

V. Phone/Fax

Practice location:
  • Phone: 601-447-1106
  • Fax:
Mailing address:
  • Phone: 601-447-1106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: JOMEKA LOTT
Title or Position: CEO
Credential:
Phone: 601-447-1106