Provider Demographics
NPI:1497832844
Name:SOUTHERN COMMUNITY HOSPICE, INC.
Entity Type:Organization
Organization Name:SOUTHERN COMMUNITY HOSPICE, INC.
Other - Org Name:COMMUNITY HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:T
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-374-6662
Mailing Address - Street 1:718 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:EASTMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31023-6736
Mailing Address - Country:US
Mailing Address - Phone:478-374-6662
Mailing Address - Fax:478-374-6663
Practice Address - Street 1:904 MOUNT VERNON RD
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-3030
Practice Address - Country:US
Practice Address - Phone:912-537-0063
Practice Address - Fax:912-537-2005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA138135H251G00000X, 315D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
No315D00000XNursing & Custodial Care FacilitiesHospice, Inpatient
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000851133AMedicaid