Provider Demographics
NPI:1205377348
Name:SOUTHEASTERN SWALLOWING DIAGNOSTICS
Entity Type:Organization
Organization Name:SOUTHEASTERN SWALLOWING DIAGNOSTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KAYLA
Authorized Official - Middle Name:
Authorized Official - Last Name:STOUT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-318-9594
Mailing Address - Street 1:8459 LEXIE LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-5796
Mailing Address - Country:US
Mailing Address - Phone:301-275-4057
Mailing Address - Fax:
Practice Address - Street 1:8459 LEXIE LN
Practice Address - Street 2:
Practice Address - City:OOLTEWAH
Practice Address - State:TN
Practice Address - Zip Code:37363-5796
Practice Address - Country:US
Practice Address - Phone:301-275-4057
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-08
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service