Provider Demographics
NPI:1619915238
Name:SOUTHERNCARE, INC.
Entity Type:Organization
Organization Name:SOUTHERNCARE, INC.
Other - Org Name:SOUTHERNCARE MONROE
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 1:3418 MEDICAL PARK DRIVE
Practice Address - Street 2:SUITE 27
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-2358
Practice Address - Country:US
Practice Address - Phone:318-387-5165
Practice Address - Fax:318-387-5548
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
LA138251G00000X
LA2203781092251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1580953Medicaid
191585Medicare Oscar/Certification
LA19-1585Medicare PIN