Provider Demographics
NPI:1336290147
Name:SOUTHEASTERN HEALTHCARE OF NORTH CAROLINA, INC.
Entity Type:Organization
Organization Name:SOUTHEASTERN HEALTHCARE OF NORTH CAROLINA, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:EVELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:919-987-2791
Mailing Address - Street 1:PO BOX 14144
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27620-4144
Mailing Address - Country:US
Mailing Address - Phone:919-212-8580
Mailing Address - Fax:
Practice Address - Street 1:3401 CARL SANDBURG CT
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-2049
Practice Address - Country:US
Practice Address - Phone:919-212-8580
Practice Address - Fax:919-212-8581
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X, 253Z00000X
NCMHL-092-746251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8303214Medicaid