Provider Demographics
NPI:1467845891
Name:SOUTHERN ELDERLY HOME CARE SERVICE
Entity Type:Organization
Organization Name:SOUTHERN ELDERLY HOME CARE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED NURSING ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KISSEY
Authorized Official - Middle Name:KENSHAWN
Authorized Official - Last Name:SHARPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-402-3759
Mailing Address - Street 1:2220 MCMILLAN DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31216-5854
Mailing Address - Country:US
Mailing Address - Phone:404-402-3759
Mailing Address - Fax:
Practice Address - Street 1:2220 MCMILLAN DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31216-5854
Practice Address - Country:US
Practice Address - Phone:404-402-3759
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-10
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility