Provider Demographics
NPI:1740285543
Name:SOUTHERN HOME RESPIRATORY CARE, INC.
Entity type:Organization
Organization Name:SOUTHERN HOME RESPIRATORY CARE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:SHANE
Authorized Official - Last Name:MOBLEY
Authorized Official - Suffix:
Authorized Official - Credentials:RRT, PSGT
Authorized Official - Phone:478-757-0759
Mailing Address - Street 1:215 SHERATON BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-1359
Mailing Address - Country:US
Mailing Address - Phone:478-757-0759
Mailing Address - Fax:478-757-0799
Practice Address - Street 1:215 SHERATON BLVD STE B
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-1359
Practice Address - Country:US
Practice Address - Phone:478-757-0759
Practice Address - Fax:478-757-0769
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHERN SLEEP TECHNOLOGIES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-06-17
Last Update Date:2008-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA01977332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA310095300OtherUS DEPARTMENT OF LABOR
GA52008983001OtherBCBS
GA0094619AMedicaid
GA310095300OtherUS DEPARTMENT OF LABOR