Provider Demographics
NPI:1821794561
Name:SOUTHERLY HOME HEALTH LLC
Entity Type:Organization
Organization Name:SOUTHERLY HOME HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLIFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-999-9243
Mailing Address - Street 1:1279 KINGSLEY AVE STE 114
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-4604
Mailing Address - Country:US
Mailing Address - Phone:904-999-9243
Mailing Address - Fax:
Practice Address - Street 1:1279 KINGSLEY AVE STE 114
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4604
Practice Address - Country:US
Practice Address - Phone:904-999-9243
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-03
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health