Provider Demographics
NPI:1538156278
Name:SOUTHERN HOME RESPIRATORY INC
Entity type:Organization
Organization Name:SOUTHERN HOME RESPIRATORY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/PRESIDENT (CORP)
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNEY
Authorized Official - Middle Name:DURIEL
Authorized Official - Last Name:AUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:CRRT
Authorized Official - Phone:334-699-2630
Mailing Address - Street 1:1386 ROSS CLARK CIR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-4117
Mailing Address - Country:US
Mailing Address - Phone:334-699-2630
Mailing Address - Fax:334-699-2630
Practice Address - Street 1:1386 ROSS CLARK CIR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-4117
Practice Address - Country:US
Practice Address - Phone:334-699-2630
Practice Address - Fax:334-699-2639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-27
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL90265332BX2000X
AL117332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51095523OtherBCBS
AL1295920001Medicare ID - Type UnspecifiedREGION C