Basic Information
| Provider Information | |||||||||
| NPI: | 1073906996 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERN CUSTOMZ LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 390 ROBIN WAY | ||||||||
| Address2: | |||||||||
| City: | EAST DUBLIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310271694 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4702175857 | ||||||||
| FaxNumber: | 4783041254 | ||||||||
| Practice Location | |||||||||
| Address1: | 390 ROBIN WAY | ||||||||
| Address2: | |||||||||
| City: | EAST DUBLIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310271694 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4702175857 | ||||||||
| FaxNumber: | 4783041254 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2015 | ||||||||
| LastUpdateDate: | 03/17/2015 | ||||||||
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| AuthorizedOfficialLastName: | MCLENDON | ||||||||
| AuthorizedOfficialFirstName: | JOHNARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4702175857 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 347C00000X | Y | Transportation Services | Private Vehicle |
No ID Information.