Basic Information
| Provider Information | |||||||||
| NPI: | 1194763037 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHERNCARE, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTHERNCARE WILLIAMSPORT | ||||||||
| 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: | 7046621306 | ||||||||
| Practice Location | |||||||||
| Address1: | 1544 E 3RD ST | ||||||||
| Address2: | STE 2 | ||||||||
| City: | WILLIAMSPORT | ||||||||
| State: | PA | ||||||||
| PostalCode: | 177015404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703231690 | ||||||||
| FaxNumber: | 5703231693 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 05/16/2016 | ||||||||
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| AuthorizedOfficialLastName: | KLEBERG | ||||||||
| AuthorizedOfficialFirstName: | JESSICA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OF LEGAL AFFAIRS | ||||||||
| AuthorizedOfficialTelephone: | 7046642876 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 16581601 | PA | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 00890434000 | 05 | PA | MEDICAID | 1008904340004 | 05 | PA | MEDICAID |