Healthcare Provider Details

I. General information

NPI: 1720617806
Provider Name (Legal Business Name): MID-SOUTH HOME CARE SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2020
Last Update Date: 09/23/2022
Certification Date: 09/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 W MASON ST STE A
GREEN BAY WI
54303-2333
US

IV. Provider business mailing address

655 BRAWLEY SCHOOL RD STE 200
MOORESVILLE NC
28117-9601
US

V. Phone/Fax

Practice location:
  • Phone: 920-471-4761
  • Fax: 920-471-4762
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 Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RH0002X
TaxonomyHospice and Palliative Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: JANET COMBS
Title or Position: VP OF LICENSURE
Credential:
Phone: 913-814-2013