MEDICARE: SOUTHERN HOME CARE SERVICES, INC

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
2	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1760960009
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN HOME CARE SERVICES, INC

Provider Business Mailing Address
First Line	:	9901 LINN STATION RD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40223-3808
Country	:	US
Telephone Number	:	502-394-2100
Fax Number	:

Provider Business Practice Location Address
First Line	:	9312 OLIVE BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63132-3208
Country	:	US
Telephone Number	:	309-682-0079
Fax Number	:

Authorized Official
Title or Position	:	PARALEGAL
Name	:	MARY A PANK
Credential	:
Telephone Number	:	502-394-2100

Provider Enumeration Date	:	07/30/2018
Last Update Date	:	07/30/2018

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