Provider Demographics
NPI:1417087990
Name:SOUTHERN MANOR REST HOME, INC.
Entity type:Organization
Organization Name:SOUTHERN MANOR REST HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SEUNG KWAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-894-9185
Mailing Address - Street 1:PO BOX 73
Mailing Address - Street 2:
Mailing Address - City:COLLEGEDALE
Mailing Address - State:TN
Mailing Address - Zip Code:37315-0073
Mailing Address - Country:US
Mailing Address - Phone:909-894-9185
Mailing Address - Fax:
Practice Address - Street 1:521 DAVENPORT RD
Practice Address - Street 2:
Practice Address - City:RUTHERFORDTON
Practice Address - State:NC
Practice Address - Zip Code:28139
Practice Address - Country:US
Practice Address - Phone:909-894-9185
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility