MEDICARE: SOUTHERN CROSS AT HOME 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	363L00000X	Nurse Practitioner	FNP/RN173575	GA

General Provider Information

NPI Number	:	1891238606
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN CROSS AT HOME LLC

Provider Business Mailing Address
First Line	:	980 BIRMINGHAM RD
Second Line	:	STE 501-330
City	:	MILTON
State	:	GA
Zip	:	30004-4417
Country	:	US
Telephone Number	:	770-317-8244
Fax Number	:

Provider Business Practice Location Address
First Line	:	980 BIRMINGHAM RD
Second Line	:	STE 501-330
City	:	MILTON
State	:	GA
Zip	:	30004-4417
Country	:	US
Telephone Number	:	770-317-8244
Fax Number	:

Authorized Official
Title or Position	:	OWNER - FOUNDER
Name	:	MS. KIMBERLY BUNKER
Credential	:	APRN, FNP-BC, NP-C
Telephone Number	:	770-317-8244

Provider Enumeration Date	:	11/28/2016
Last Update Date	:	11/28/2016

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