Provider Demographics
NPI:1902848443
Name:SOUTHERNCARE, INC.
Entity Type:Organization
Organization Name:SOUTHERNCARE, INC.
Other - Org Name:GENTIVA II
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OF LICENSURE
Authorized Official - Prefix:MS
Authorized Official - First Name:JANET
Authorized Official - Middle Name:
Authorized Official - Last Name:COMBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-664-2876
Mailing Address - Street 1:PO BOX 4060
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-4060
Mailing Address - Country:US
Mailing Address - Phone:704-664-2876
Mailing Address - Fax:704-664-1306
Practice Address - Street 1:5330 PETERS CREEK ROAD NW
Practice Address - Street 2:SUITE D-1
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24019-3853
Practice Address - Country:US
Practice Address - Phone:540-366-0927
Practice Address - Fax:540-366-0989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAHSP 130251G00000X
VAHSP14130251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010299098Medicaid
491582Medicare Oscar/Certification
VA010299098Medicaid