Provider Demographics
NPI:1477928760
Name:SOUTHEASTERN REGIONAL PHYSICIAN SERVICES
Entity Type:Organization
Organization Name:SOUTHEASTERN REGIONAL PHYSICIAN SERVICES
Other - Org Name:SOUTHEASTERN OCCUPATIONAL HEALTHWORKS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:HENLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-737-3147
Mailing Address - Street 1:2002 N CEDAR ST STE B
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-3926
Mailing Address - Country:US
Mailing Address - Phone:910-272-3048
Mailing Address - Fax:910-738-3764
Practice Address - Street 1:500 W 27TH ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-3021
Practice Address - Country:US
Practice Address - Phone:910-272-9675
Practice Address - Fax:910-272-9276
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-11
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty