Basic Information
| Provider Information | |||||||||
| NPI: | 1023056405 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERNCARE, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SOUTHERNCARE CLANTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 655 BRAWLEY SCHOOL RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MOORESVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281179125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046642876 | ||||||||
| FaxNumber: | 7046641306 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | CLANTON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350452329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2052803793 | ||||||||
| FaxNumber: | 2052803863 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 01/20/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ABELL | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF COMPLIANCE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7046642876 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | AL | N | Agencies | Hospice Care, Community Based | 251G00000X | 10519 | AL | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | PIC1649E | 05 | AL | MEDICAID | E1102 | 01 | AL | STATE LICENSE | OTHER |