Provider Demographics
NPI:1114390861
Name:SOUTHERN HOME CARE ASSISTANCE
Entity Type:Organization
Organization Name:SOUTHERN HOME CARE ASSISTANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:R
Authorized Official - Last Name:PHILYAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-525-8886
Mailing Address - Street 1:2836 MALVERN AVE STE G
Mailing Address - Street 2:
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71901-8363
Mailing Address - Country:US
Mailing Address - Phone:501-525-8886
Mailing Address - Fax:
Practice Address - Street 1:2836 MALVERN AVE STE G
Practice Address - Street 2:
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71901-8363
Practice Address - Country:US
Practice Address - Phone:501-525-8886
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-03
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR206214797Medicaid