Basic Information
| Provider Information | |||||||||
| NPI: | 1851331615 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERNCARE, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTHERNCARE FORT WAYNE | ||||||||
| 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: | 7557 W JEFFERSON BLVD | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468044131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604326075 | ||||||||
| FaxNumber: | 2604321275 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2006 | ||||||||
| LastUpdateDate: | 05/16/2016 | ||||||||
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| AuthorizedOfficialLastName: | KLEBERG | ||||||||
| AuthorizedOfficialFirstName: | JESSICA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP OF LEGAL AFFAIRS | ||||||||
| AuthorizedOfficialTelephone: | 7046642876 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | 060025631 | IN | N | Agencies | Hospice Care, Community Based | 251G00000X | 14-002563-1 | IN | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 200424070A | 05 | IN | MEDICAID |