Provider Demographics
NPI:1790465342
Name:SOUTHERN PROFESSIONAL HOME CARE LLC
Entity Type:Organization
Organization Name:SOUTHERN PROFESSIONAL HOME CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:GWENDOLYN
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, BSW
Authorized Official - Phone:864-419-0167
Mailing Address - Street 1:1200 WOODRUFF RD STE A3
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-5732
Mailing Address - Country:US
Mailing Address - Phone:864-419-0167
Mailing Address - Fax:864-213-6317
Practice Address - Street 1:1200 WOODRUFF RD STE A3
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-5732
Practice Address - Country:US
Practice Address - Phone:864-419-0167
Practice Address - Fax:864-213-6317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-19
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health