=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639112410
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERNCARE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2006
-----------------------------------------------------
Last Update Date | 06/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 501 E COMMERCE ST
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36037-2313
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-382-1406
-----------------------------------------------------
Fax | 334-382-1409
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 4060
-----------------------------------------------------
City | MOORESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28117-4060
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-664-2876
-----------------------------------------------------
Fax | 704-664-1306
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OF LICENSURE
-----------------------------------------------------
Name | JANET COMBS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 913-814-2013
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251G00000X
-----------------------------------------------------
Taxonomy Name | Community Based Hospice Care Agency
-----------------------------------------------------
License Number | 10525
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------