Provider Demographics
NPI:1386682755
Name:SOUTHERNCARE, INC.
Entity Type:Organization
Organization Name:SOUTHERNCARE, INC.
Other - Org Name:SOUTHERNCARE LAFAYETTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF LEGAL AFFAIRS
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:KLEBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-664-2876
Mailing Address - Street 1:655 BRAWLEY SCHOOL RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-9125
Mailing Address - Country:US
Mailing Address - Phone:704-664-2876
Mailing Address - Fax:704-664-1306
Practice Address - Street 1:935 MEZZANINE DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-8645
Practice Address - Country:US
Practice Address - Phone:765-448-4732
Practice Address - Fax:765-448-4741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN040039001251G00000X
IN13-003900-2251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200469930AMedicaid
IN200469930AMedicaid
IN15-1584Medicare PIN