1003854472 NPI number — SOUTHERNCARE, INC.

Table of content: (NPI 1003854472)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003854472 NPI number — SOUTHERNCARE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERNCARE, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SOUTHERNCARE SAGINAW
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003854472
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4060
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOORESVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28117-4060
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-664-2876
Provider Business Mailing Address Fax Number:
704-664-1306

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6272 STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAGINAW
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48603-3429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-790-7533
Provider Business Practice Location Address Fax Number:
989-790-7574
Provider Enumeration Date:
06/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
COMBS
Authorized Official First Name:
JANET
Authorized Official Middle Name:
Authorized Official Title or Position:
VP OF LICENSURE
Authorized Official Telephone Number:
913-814-2013

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X , with the licence number:  733514 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251G00000X , with the licence number: 1041000082 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 15 4747077 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 15/4747077 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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