1689890642 NPI number — SOUTHERNCARE, INC

Table of content: (NPI 1689890642)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689890642 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 CEDAR RAPIDS
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:
1689890642
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3536 VANN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35235-3221
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-655-4809
Provider Business Mailing Address Fax Number:
205-655-0587

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5005 BOWLING ST SW
Provider Second Line Business Practice Location Address:
STE 3
Provider Business Practice Location Address City Name:
CEDAR RAPIDS
Provider Business Practice Location Address State Name:
IA
Provider Business Practice Location Address Postal Code:
52404-5070
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
319-364-2204
Provider Business Practice Location Address Fax Number:
319-364-4933
Provider Enumeration Date:
04/18/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PARDY
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
205-655-4809

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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