Provider Demographics
NPI:1245379882
Name:SOUTHERN HOME HEALTH AT KWCC INC
Entity Type:Organization
Organization Name:SOUTHERN HOME HEALTH AT KWCC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATE BILLING DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ROBERTA
Authorized Official - Middle Name:A
Authorized Official - Last Name:CARON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-333-1372
Mailing Address - Street 1:5860 COLLEGE RD
Mailing Address - Street 2:
Mailing Address - City:KEY WEST
Mailing Address - State:FL
Mailing Address - Zip Code:33040-4314
Mailing Address - Country:US
Mailing Address - Phone:305-296-2450
Mailing Address - Fax:305-296-9197
Practice Address - Street 1:5860 COLLEGE RD
Practice Address - Street 2:
Practice Address - City:KEY WEST
Practice Address - State:FL
Practice Address - Zip Code:33040-4314
Practice Address - Country:US
Practice Address - Phone:305-296-2450
Practice Address - Fax:305-296-9197
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108357Medicare ID - Type Unspecified