Provider Demographics
NPI:1376872895
Name:SOUTHERN HOME CARE SERVICES, INC.
Entity Type:Organization
Organization Name:SOUTHERN HOME CARE SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:WHOBREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-630-7249
Mailing Address - Street 1:805 N WHITTINGTON PKWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-5186
Mailing Address - Country:US
Mailing Address - Phone:502-394-2100
Mailing Address - Fax:
Practice Address - Street 1:1124 SAM RITTENBERG BLVD STE 8
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-3362
Practice Address - Country:US
Practice Address - Phone:502-394-2100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-11
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCEX0899Medicaid