Provider Demographics
NPI:1629573134
Name:SOUTHEASTERN DME LLC
Entity Type:Organization
Organization Name:SOUTHEASTERN DME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REINALDO
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-740-0899
Mailing Address - Street 1:29 JACKS CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:GA
Mailing Address - Zip Code:31324-9344
Mailing Address - Country:US
Mailing Address - Phone:336-740-0899
Mailing Address - Fax:
Practice Address - Street 1:200 S INDIAN RIVER DR STE 300
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950
Practice Address - Country:US
Practice Address - Phone:772-460-6091
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-27
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies