Provider Demographics
NPI:1063746204
Name:SOUTHERN HOME CARE SERVICES, INC.
Entity type:Organization
Organization Name:SOUTHERN HOME CARE SERVICES, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT & DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARGARET
Authorized Official - Middle Name:SHERRY
Authorized Official - Last Name:PEMBERTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-272-3466
Mailing Address - Street 1:805 N WHITTINGTON PKWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-7101
Mailing Address - Country:US
Mailing Address - Phone:800-866-0860
Mailing Address - Fax:
Practice Address - Street 1:515 E 3RD AVE
Practice Address - Street 2:
Practice Address - City:CORDELE
Practice Address - State:GA
Practice Address - Zip Code:31015-3608
Practice Address - Country:US
Practice Address - Phone:229-242-2797
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-21
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X
GA315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000552538BIMedicaid