Provider Demographics
NPI:1740228832
Name:SOUTHERNCARE, INC.
Entity Type:Organization
Organization Name:SOUTHERNCARE, INC.
Other - Org Name:SOUTHERNCARE SOUTH BEND
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF LICENSURE
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:COMBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-814-2013
Mailing Address - Street 1:PO BOX 4060
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-4060
Mailing Address - Country:US
Mailing Address - Phone:704-664-2876
Mailing Address - Fax:704-664-1306
Practice Address - Street 1:1626 E DAY RD
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-3469
Practice Address - Country:US
Practice Address - Phone:574-259-0895
Practice Address - Fax:574-259-0899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN050037231251G00000X
IN14-003723-1251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200451230AMedicaid
IN200451230AMedicaid
IN15-1582Medicare PIN