Provider Demographics
NPI:1750320180
Name:SOUTHERNCARE, INC.
Entity Type:Organization
Organization Name:SOUTHERNCARE, INC.
Other - Org Name:SOUTHERNCARE MONTGOMERY
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 1:7067 SYDNEY CURV
Practice Address - Street 2:SUITE B
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-3509
Practice Address - Country:US
Practice Address - Phone:334-260-2273
Practice Address - Fax:334-260-2274
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
AL10259251G00000X
AL10529251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALPIC1553EMedicaid
AL01-1553Medicare PIN
011553Medicare Oscar/Certification