Provider Demographics
NPI:1720458508
Name:SOUTHERNCARE, INC,
Entity type:Organization
Organization Name:SOUTHERNCARE, INC,
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OF LICENSURE
Authorized Official - Prefix:MS
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:COMBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-664-2876
Mailing Address - Street 1:PO BOX 4060
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-4060
Mailing Address - Country:US
Mailing Address - Phone:704-664-2876
Mailing Address - Fax:704-664-1306
Practice Address - Street 1:11835 FISHING POINT DR STE 102B
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-2584
Practice Address - Country:US
Practice Address - Phone:757-874-1237
Practice Address - Fax:757-898-3516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-06
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1720458508Medicaid