Provider Demographics
NPI:1417488693
Name:SOUTHEAST SPECIALTIES,LLC
Entity Type:Organization
Organization Name:SOUTHEAST SPECIALTIES,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:WOODS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-344-7713
Mailing Address - Street 1:PO BOX 467
Mailing Address - Street 2:
Mailing Address - City:HAYTI
Mailing Address - State:MO
Mailing Address - Zip Code:63851
Mailing Address - Country:US
Mailing Address - Phone:573-724-4606
Mailing Address - Fax:
Practice Address - Street 1:210 S 3RD ST
Practice Address - Street 2:
Practice Address - City:HAYTI
Practice Address - State:MO
Practice Address - Zip Code:63851-1618
Practice Address - Country:US
Practice Address - Phone:573-724-4606
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services