Provider Demographics
NPI:1407486525
Name:SOUTHERN COMFORT HOME HEALTHCARE, LLC
Entity Type:Organization
Organization Name:SOUTHERN COMFORT HOME HEALTHCARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DARRIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FORTENBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-915-2010
Mailing Address - Street 1:2443 BETHESDA OAKS DR
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28056-0001
Mailing Address - Country:US
Mailing Address - Phone:704-915-2010
Mailing Address - Fax:704-879-9225
Practice Address - Street 1:1006 UNION RD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-0466
Practice Address - Country:US
Practice Address - Phone:704-915-2010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-16
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care