=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033715248
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN PINES HEALTHCARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2020
-----------------------------------------------------
Last Update Date | 07/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6410 SOUTHWEST BLVD STE 127
-----------------------------------------------------
City | BENBROOK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76109-6918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-553-2276
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6410 SOUTHWEST BLVD STE 127
-----------------------------------------------------
City | BENBROOK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76109-6918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-553-2276
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | AMBER L TUELLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-207-2726
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251G00000X
-----------------------------------------------------
Taxonomy Name | Community Based Hospice Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------