Basic Information
| Provider Information | |||||||||
| NPI: | 1174559710 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MID-SOUTH HOME CARE SERVICES, LLC | ||||||||
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| OtherOrganizationName: | MID-SOUTH RESPIRATORY SERVICES & HME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12900 FOSTER ST | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | OVERLAND PARK | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662132649 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2740 HEADLAND AVE | ||||||||
| Address2: | |||||||||
| City: | DOTHAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363031236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347923200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2006 | ||||||||
| LastUpdateDate: | 03/24/2022 | ||||||||
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| AuthorizedOfficialLastName: | COMBS | ||||||||
| AuthorizedOfficialFirstName: | JANET | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF LICENSURE | ||||||||
| AuthorizedOfficialTelephone: | 9138142013 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GENTIVA HEALTH SERVICES, INC. | ||||||||
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| NPICertificationDate: | 03/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BP3500X | N | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition | 332BX2000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 515-21704 | 01 | AL | G2 | OTHER | 009909965 | 05 | AL | MEDICAID |