Provider Demographics
NPI:1326558867
Name:SOUTH REGIONAL PERSONAL CARE SERVICE, LLC
Entity Type:Organization
Organization Name:SOUTH REGIONAL PERSONAL CARE SERVICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNAH
Authorized Official - Middle Name:
Authorized Official - Last Name:HICKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-367-1649
Mailing Address - Street 1:13811 PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70726-8819
Mailing Address - Country:US
Mailing Address - Phone:225-333-2178
Mailing Address - Fax:
Practice Address - Street 1:10319 OLD HAMMOND HWY STE B1
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-8288
Practice Address - Country:US
Practice Address - Phone:225-367-1649
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-11
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X
LA2203782592251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health