Provider Demographics
NPI:1609309798
Name:SOUTHERN ROOTS IN-HOME CARE LLC
Entity Type:Organization
Organization Name:SOUTHERN ROOTS IN-HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SQUIRES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-703-2229
Mailing Address - Street 1:301 S BENTON ST MH
Mailing Address - Street 2:
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-0301
Mailing Address - Country:US
Mailing Address - Phone:573-667-0028
Mailing Address - Fax:573-667-0028
Practice Address - Street 1:301 S BENTON ST MH
Practice Address - Street 2:
Practice Address - City:MOREHOUSE
Practice Address - State:MO
Practice Address - Zip Code:63868-0301
Practice Address - Country:US
Practice Address - Phone:573-667-0028
Practice Address - Fax:573-667-0028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-06
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO985864251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health