Basic Information
| Provider Information | |||||||||
| NPI: | 1134150931 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERNCARE INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTHERNCARE FT WORTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2204 LAKESHORE DR | ||||||||
| Address2: | SUITE 475 | ||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352096705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2058684400 | ||||||||
| FaxNumber: | 2058684401 | ||||||||
| Practice Location | |||||||||
| Address1: | 68853550 HULEN STREET | ||||||||
| Address2: | STE B | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761076885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177638688 | ||||||||
| FaxNumber: | 8177638603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 05/27/2009 | ||||||||
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| AuthorizedOfficialLastName: | PARSONS | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2058684400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 009786 | TX | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 001013999 | 05 | TX | MEDICAID |