Provider Demographics
NPI:1124068937
Name:SOUTHERNCARE, INC.
Entity type:Organization
Organization Name:SOUTHERNCARE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OF LEGAL AFFAIRS
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-664-2876
Mailing Address - Street 1:655 BRAWLEY SCHOOL RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-9125
Mailing Address - Country:US
Mailing Address - Phone:704-664-2876
Mailing Address - Fax:704-662-1306
Practice Address - Street 1:3206 LONGMIRE DR
Practice Address - Street 2:SUITE C
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-5858
Practice Address - Country:US
Practice Address - Phone:979-696-8880
Practice Address - Fax:979-696-9922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX014938251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001012411Medicaid
TX45-1747Medicare PIN
451747Medicare Oscar/Certification