Provider Demographics
NPI:1629030721
Name:SOUTHEAST HOMECARE & RESPIRATORY SERVICES
Entity Type:Organization
Organization Name:SOUTHEAST HOMECARE & RESPIRATORY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AREA MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:C
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-736-3664
Mailing Address - Street 1:PO BOX 2120
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-2120
Mailing Address - Country:US
Mailing Address - Phone:706-736-3664
Mailing Address - Fax:
Practice Address - Street 1:2150 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-6713
Practice Address - Country:US
Practice Address - Phone:706-736-7334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-04
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE2074Medicaid
GA00951145AMedicaid
GA00951145AMedicaid