MEDICARE: SOUTHERN CARE AND COMFORT IN HOME AGENCY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1275991861
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN CARE AND COMFORT IN HOME AGENCY, LLC

Provider Business Mailing Address
First Line	:	225 PHYSICIANS PARK
Second Line	:	SUITE 301
City	:	POPLAR BLUFF
State	:	MO
Zip	:	63901-3935
Country	:	US
Telephone Number	:	573-686-2273
Fax Number	:	573-686-4663

Provider Business Practice Location Address
First Line	:	225 PHYSICIANS PARK
Second Line	:	SUITE 301
City	:	POPLAR BLUFF
State	:	MO
Zip	:	63901-3935
Country	:	US
Telephone Number	:	573-686-2273
Fax Number	:	573-686-4663

Authorized Official
Title or Position	:	OWNER/MEMBER
Name	:	KIMBERLY WILSON
Credential	:
Telephone Number	:	573-686-2273

Provider Enumeration Date	:	02/10/2016
Last Update Date	:	02/10/2016

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