=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467927228
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN MADE HOME CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2018
-----------------------------------------------------
Last Update Date | 10/09/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12531 CLIPPER DR STE 202
-----------------------------------------------------
City | WOODBRIDGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22192-2355
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-490-2273
-----------------------------------------------------
Fax | 703-782-1581
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13806 BREEZY RIDGE WAY UNIT 201
-----------------------------------------------------
City | WOODBRIDGE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22191-1487
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-477-4036
-----------------------------------------------------
Fax | 703-782-1581
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATIVE DIRECTOR
-----------------------------------------------------
Name | SHAMIRA GAINES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 703-490-2273
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------