1801471172 NPI number — SOUTHERN CHARM FAMILY HEALTHCARE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801471172 NPI number — SOUTHERN CHARM FAMILY HEALTHCARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN CHARM FAMILY HEALTHCARE
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:
6
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:
1801471172
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
515 BELLE OAK PL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRANDON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39042-8111
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-829-6151
Provider Business Mailing Address Fax Number:
769-241-0044

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 HIGHWAY 49 S STE 46
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RICHLAND
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39218-9438
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-829-6151
Provider Business Practice Location Address Fax Number:
769-241-0044
Provider Enumeration Date:
03/17/2021

Additional Information

Authorized Official

Authorized Official Last Name:
FOSTER
Authorized Official First Name:
KELLI
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
601-829-6151

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00936767 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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