=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972418374
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2026
-----------------------------------------------------
Last Update Date | 08/19/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4665 MAIN ST STE 1A
-----------------------------------------------------
City | JASPER
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37347-4604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-658-5961
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4665 MAIN ST STE 1A
-----------------------------------------------------
City | JASPER
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37347-4604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-658-5961
-----------------------------------------------------
Fax | 423-658-5964
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | ANGIE MATTINGLY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 502-394-2100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 372500000X
-----------------------------------------------------
Taxonomy Name | Chore Provider
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 3747P1801X
-----------------------------------------------------
Taxonomy Name | Personal Care Attendant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------