Provider Demographics
NPI:1144600875
Name:SOUTHEAST HOSPICE, LLC,
Entity Type:Organization
Organization Name:SOUTHEAST HOSPICE, LLC,
Other - Org Name:SOUTHEAST HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:STUART
Authorized Official - Middle Name:
Authorized Official - Last Name:PRATHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-364-3108
Mailing Address - Street 1:1203 GEORGE C. WILSON DRIVE SUITE A
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-4502
Mailing Address - Country:US
Mailing Address - Phone:706-364-3108
Mailing Address - Fax:706-364-3315
Practice Address - Street 1:1203 GEORGE C. WILSON DRIVE SUITE A
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-4502
Practice Address - Country:US
Practice Address - Phone:706-364-3108
Practice Address - Fax:706-364-3315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-08
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA121-0416-H251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA121-0416-HOtherGA HOSPICE LICENSE
GA111769Medicare Oscar/Certification