Provider Demographics
NPI:1043095599
Name:SOUTHERN, BILLY JOE JR
Entity Type:Individual
Prefix:
First Name:BILLY
Middle Name:JOE
Last Name:SOUTHERN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3873 MAPLE ACRES RD
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:24701-5055
Mailing Address - Country:US
Mailing Address - Phone:304-324-8819
Mailing Address - Fax:
Practice Address - Street 1:3873 MAPLE ACRES RD
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24701-5055
Practice Address - Country:US
Practice Address - Phone:304-324-8819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-31
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant