Provider Demographics
NPI:1740592773
Name:SOUTHERN SENIOR LIVING
Entity Type:Organization
Organization Name:SOUTHERN SENIOR LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ADMINSTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETH
Authorized Official - Middle Name:M
Authorized Official - Last Name:HARPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:912-383-9883
Mailing Address - Street 1:215 SELLERS ST
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-4609
Mailing Address - Country:US
Mailing Address - Phone:912-383-9883
Mailing Address - Fax:912-383-8571
Practice Address - Street 1:215 SELLERS ST
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-4609
Practice Address - Country:US
Practice Address - Phone:912-383-9883
Practice Address - Fax:912-383-8571
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-07
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034-01-011-1310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA390875605AMedicaid