Provider Demographics
NPI:1316987829
Name:SOUTHERNCARE, INC.
Entity type:Organization
Organization Name:SOUTHERNCARE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF COMPLIANCE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:R
Authorized Official - Last Name:PRIEST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-374-5914
Mailing Address - Street 1:6363 N STATE HIGHWAY 161
Mailing Address - Street 2:SUITE 115
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-2269
Mailing Address - Country:US
Mailing Address - Phone:469-374-5900
Mailing Address - Fax:469-374-5901
Practice Address - Street 1:5800 N I35
Practice Address - Street 2:STE 200 B
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76207-1438
Practice Address - Country:US
Practice Address - Phone:940-243-0901
Practice Address - Fax:940-243-0904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2013-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX015010251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001013519Medicaid
TX001013519Medicaid