MEDICARE: SOUTHERN COMFORT PCA, 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	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1407319833
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN COMFORT PCA, LLC

Provider Business Mailing Address
First Line	:	4428 E AZURE AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89115-6028
Country	:	US
Telephone Number	:	702-417-4702
Fax Number	:

Provider Business Practice Location Address
First Line	:	4428 E AZURE AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89115-6028
Country	:	US
Telephone Number	:	702-417-4702
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	QUANIKA SIMPSON-JACKSON
Credential	:
Telephone Number	:	702-417-4702

Provider Enumeration Date	:	04/11/2019
Last Update Date	:	04/11/2019

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