Healthcare Provider Details

I. General information

NPI: 1629307145
Provider Name (Legal Business Name): SOUTHERN HOME CARE SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2009
Last Update Date: 12/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1109 48TH AVE N SUITE 111
MYRTLE BEACH SC
29577-5417
US

IV. Provider business mailing address

9901 LINN STATION RD
LOUISVILLE KY
40223-3808
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral 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
IdentifierEX0954
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name: MS. DEENA OMBRES
Title or Position: PRIVACY OFFICER
Credential:
Phone: 502-394-2387