Provider Demographics
NPI:1063887032
Name:SOUTHERN HOME PRIVATE CARE LLC
Entity type:Organization
Organization Name:SOUTHERN HOME PRIVATE CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:M
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-686-1589
Mailing Address - Street 1:906 20TH AVE
Mailing Address - Street 2:STE 115
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-5153
Mailing Address - Country:US
Mailing Address - Phone:601-686-1589
Mailing Address - Fax:
Practice Address - Street 1:906 20TH AVE
Practice Address - Street 2:STE 115
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-5153
Practice Address - Country:US
Practice Address - Phone:601-686-1589
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-02
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty