Provider Demographics
NPI:1275990004
Name:SOUTHERN LIVING HOME CARE SERVICES
Entity Type:Organization
Organization Name:SOUTHERN LIVING HOME CARE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ZANY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-710-1833
Mailing Address - Street 1:1203 W LEBANON ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:NC
Mailing Address - Zip Code:27030-2244
Mailing Address - Country:US
Mailing Address - Phone:336-710-1833
Mailing Address - Fax:336-374-2803
Practice Address - Street 1:177 WINDGATE CT
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-7821
Practice Address - Country:US
Practice Address - Phone:336-710-1833
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-25
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC4188251E00000X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No385H00000XRespite Care FacilityRespite Care