MEDICARE: SOUTHERN HOME RESPIRATORY OF FL

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	332B00000X	Durable Medical Equipment & Medical Supplies	1312609	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	R9765	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1578587317
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN HOME RESPIRATORY OF FL

Provider Business Mailing Address
First Line	:	5426 CLIFFF ST
Second Line	:
City	:	GRACEVILLE
State	:	FL
Zip	:	32440-1734
Country	:	US
Telephone Number	:	850-263-3800
Fax Number	:	850-263-5600

Provider Business Practice Location Address
First Line	:	5426 CLIFFF ST
Second Line	:
City	:	GRACEVILLE
State	:	FL
Zip	:	32440-1734
Country	:	US
Telephone Number	:	850-263-3800
Fax Number	:	850-263-5600

Authorized Official
Title or Position	:	CO OWNER SECRETARY TREASURER
Name	:	MRS. GLENDA J HOWARD
Credential	:
Telephone Number	:	850-263-3800

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	10/25/2007

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Directions to “SOUTHERN HOME RESPIRATORY OF FL ” Practice Location

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