Provider Demographics
NPI:1619986601
Name:SOUTHEAST THERAPY SERVICES INC
Entity Type:Organization
Organization Name:SOUTHEAST THERAPY SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-742-3267
Mailing Address - Street 1:PO BOX 368
Mailing Address - Street 2:
Mailing Address - City:OAKES
Mailing Address - State:ND
Mailing Address - Zip Code:58474-0368
Mailing Address - Country:US
Mailing Address - Phone:701-742-3267
Mailing Address - Fax:701-742-3201
Practice Address - Street 1:21 WILEY AVENUE SOUTH
Practice Address - Street 2:
Practice Address - City:LIDGERWOOD
Practice Address - State:ND
Practice Address - Zip Code:58053-4001
Practice Address - Country:US
Practice Address - Phone:701-538-4189
Practice Address - Fax:701-538-4319
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHEAST THERAPY SERVICES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-07
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND55416Medicaid
NDCG3429OtherTRAVELERS MEDICARE
ND1346007OtherBCBS ND CLNIC #
NDCG3429OtherTRAVELERS MEDICARE
NDCG3429Medicare PIN