Provider Demographics
NPI:1346383783
Name:SOUTHERN LIVING HOME CARE AGENCY INC.
Entity Type:Organization
Organization Name:SOUTHERN LIVING HOME CARE AGENCY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:THAD
Authorized Official - Last Name:WHITEHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-654-3752
Mailing Address - Street 1:PO BOX 314
Mailing Address - Street 2:
Mailing Address - City:CHADBOURN
Mailing Address - State:NC
Mailing Address - Zip Code:28431-0314
Mailing Address - Country:US
Mailing Address - Phone:910-654-3752
Mailing Address - Fax:910-654-4581
Practice Address - Street 1:506 JOE BROWN HWY N
Practice Address - Street 2:
Practice Address - City:CHADBOURN
Practice Address - State:NC
Practice Address - Zip Code:28431-7203
Practice Address - Country:US
Practice Address - Phone:910-654-3752
Practice Address - Fax:910-654-4581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC2982251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6601266Medicaid