Provider Demographics
NPI:1114002227
Name:SOUTHLAND NURSING HOME, LLC
Entity Type:Organization
Organization Name:SOUTHLAND NURSING HOME, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SWANSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-638-6141
Mailing Address - Street 1:500 SHIVERS TER
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:AL
Mailing Address - Zip Code:36756-3534
Mailing Address - Country:US
Mailing Address - Phone:334-683-6141
Mailing Address - Fax:334-683-6142
Practice Address - Street 1:500 SHIVERS TER
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:AL
Practice Address - Zip Code:36756-3534
Practice Address - Country:US
Practice Address - Phone:334-683-6141
Practice Address - Fax:334-683-6142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALN5302314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL47-5104-0SMedicaid
AL47-5104-0SMedicaid