Provider Demographics
NPI:1326036138
Name:SOUTHEASTERN INTEGRATED CARE
Entity Type:Organization
Organization Name:SOUTHEASTERN INTEGRATED CARE
Other - Org Name:LUMBER RIVER FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:NIKKIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-467-8799
Mailing Address - Street 1:3005 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-2984
Mailing Address - Country:US
Mailing Address - Phone:910-738-7789
Mailing Address - Fax:910-738-7599
Practice Address - Street 1:3005 N ELM ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2984
Practice Address - Country:US
Practice Address - Phone:910-738-7789
Practice Address - Fax:910-738-7599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-06
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care