Healthcare Provider Details

I. General information

NPI: 1093799439
Provider Name (Legal Business Name): SOUTH ROANOKE LIFE CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3823 FRANKLIN RD SW
ROANOKE VA
24014
US

IV. Provider business mailing address

3823 FRANKLIN RD SW
ROANOKE VA
24014
US

V. Phone/Fax

Practice location:
  • Phone: 540-344-4325
  • Fax: 540-342-0316
Mailing address:
  • Phone: 540-344-4325
  • Fax: 540-342-0316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number49-5002
License Number StateVA

VIII. Authorized Official

Name: CASSANDRA GALLANT
Title or Position: COMPLIANCE & PRIVACY OFFICER
Credential:
Phone: 540-774-4263