Provider Demographics
NPI:1992214084
Name:SOUTHERN LIVING FOR SENIORS OF LOUISBURG NC
Entity Type:Organization
Organization Name:SOUTHERN LIVING FOR SENIORS OF LOUISBURG NC
Other - Org Name:SOUTHERN LIVING FOR SENIORS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-253-5990
Mailing Address - Street 1:1786 NE COUNTY ROAD 150
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:FL
Mailing Address - Zip Code:32340-3617
Mailing Address - Country:US
Mailing Address - Phone:850-464-4343
Mailing Address - Fax:
Practice Address - Street 1:361 LEONARD RD
Practice Address - Street 2:
Practice Address - City:LOUISBURG
Practice Address - State:NC
Practice Address - Zip Code:27549-8412
Practice Address - Country:US
Practice Address - Phone:850-253-5990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-21
Last Update Date:2017-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0000000000Medicaid