Healthcare Provider Details

I. General information

NPI: 1275990004
Provider Name (Legal Business Name): SOUTHERN LIVING HOME CARE SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2016
Last Update Date: 01/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

177 WINDGATE CT
MOUNT AIRY NC
27030-7821
US

IV. Provider business mailing address

1203 W LEBANON ST
MOUNT AIRY NC
27030-2244
US

V. Phone/Fax

Practice location:
  • Phone: 336-710-1833
  • Fax:
Mailing address:
  • Phone: 336-710-1833
  • Fax: 336-374-2803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberHC4188
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License NumberHC4188
License Number StateNC

VIII. Authorized Official

Name: MR. ZANY GRAY
Title or Position: ADMINISTRATOR
Credential:
Phone: 336-710-1833