Basic Information
| Provider Information | |||||||||
| NPI: | 1093753188 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERNCARE, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTHERNCARE JACKSON/ ANN ARBOR | ||||||||
| 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: | 1965 BOARDMAN RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492021979 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177886838 | ||||||||
| FaxNumber: | 5177886839 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2006 | ||||||||
| LastUpdateDate: | 10/12/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COMBS | ||||||||
| AuthorizedOfficialFirstName: | JANET | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OF LICENSURE | ||||||||
| AuthorizedOfficialTelephone: | 9138142013 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 383513 | MI | N | Agencies | Hospice Care, Community Based | 251G00000X | 1041000079 | MI | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 15/4610886 | 05 | MI | MEDICAID | 4610886 | 05 | MI | MEDICAID |