1497443782 NPI number — SOUTHERN HOSPITALITY AT HOME, INC.

Table of content: (NPI 1497443782)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497443782 NPI number — SOUTHERN HOSPITALITY AT HOME, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN HOSPITALITY AT HOME, 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:
Provider Other Organization Name Type Code:
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:
1497443782
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4786 HIGH OAK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MACON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31210-5647
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
912-314-3811
Provider Business Mailing Address Fax Number:
478-259-3820

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
511 N COBB ST STE 4
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MILLEDGEVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31061-3278
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-295-0946
Provider Business Practice Location Address Fax Number:
478-295-0434
Provider Enumeration Date:
04/26/2023

Additional Information

Authorized Official

Authorized Official Last Name:
BACON
Authorized Official First Name:
KIERRA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO/OWNER
Authorized Official Telephone Number:
478-295-0946

Provider Taxonomy Codes

  • Taxonomy code: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 374U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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