Provider Demographics
NPI:1275698706
Name:SOUTHEASTERN REGIONAL MENTAL HEALTH CENTER
Entity Type:Organization
Organization Name:SOUTHEASTERN REGIONAL MENTAL HEALTH CENTER
Other - Org Name:SOUTHEASTERN REGIONAL MH DD SAS
Other - Org Type:Other Name
Authorized Official - Title/Position:FINANCE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICKI
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-272-1230
Mailing Address - Street 1:450 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28360-9494
Mailing Address - Country:US
Mailing Address - Phone:910-272-1230
Mailing Address - Fax:910-272-9397
Practice Address - Street 1:450 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28360-9494
Practice Address - Country:US
Practice Address - Phone:910-272-1230
Practice Address - Fax:910-272-9397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-26
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005444Medicaid
NC5901284Medicaid