Provider Demographics
NPI:1841230653
Name:SOUTHERN HOME RESPIRATORY & EQUIPMENT, INC.
Entity Type:Organization
Organization Name:SOUTHERN HOME RESPIRATORY & EQUIPMENT, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSALESI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:484-246-9499
Mailing Address - Street 1:3325 BARTLETT BLVD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32811-6428
Mailing Address - Country:US
Mailing Address - Phone:407-206-0040
Mailing Address - Fax:407-206-0010
Practice Address - Street 1:185 REDWOOD AVE STE 102B&101
Practice Address - Street 2:
Practice Address - City:PENNINGTON GAP
Practice Address - State:VA
Practice Address - Zip Code:24277-0018
Practice Address - Country:US
Practice Address - Phone:276-546-2050
Practice Address - Fax:276-546-6030
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AEROCARE HOLDINGS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-08
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10001234Medicaid
VA104999OtherBLUE CROSS BLUE SHIELD
VA104999OtherBLUE CROSS BLUE SHIELD