Provider Demographics
NPI:1295193589
Name:SOUTHERN GRACE SERVICES
Entity Type:Organization
Organization Name:SOUTHERN GRACE SERVICES
Other - Org Name:SOUTHERN GRACE - SENIOR HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALISA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERTEAU
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:901-491-3456
Mailing Address - Street 1:1208A CARTERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:PETAL
Mailing Address - State:MS
Mailing Address - Zip Code:39465-3115
Mailing Address - Country:US
Mailing Address - Phone:601-602-5411
Mailing Address - Fax:601-602-5410
Practice Address - Street 1:1208A CARTERVILLE RD
Practice Address - Street 2:
Practice Address - City:PETAL
Practice Address - State:MS
Practice Address - Zip Code:39465-3115
Practice Address - Country:US
Practice Address - Phone:601-602-5411
Practice Address - Fax:601-602-5410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-02
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care