Provider Demographics
NPI:1639215171
Name:SOUTHEAST COMMUNITY SERVICE AGENCY
Entity Type:Organization
Organization Name:SOUTHEAST COMMUNITY SERVICE AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:RESHONDA
Authorized Official - Middle Name:SHANAY
Authorized Official - Last Name:GOINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-634-6966
Mailing Address - Street 1:1501 RIVERSIDE DR
Mailing Address - Street 2:105
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37406-4309
Mailing Address - Country:US
Mailing Address - Phone:423-634-6966
Mailing Address - Fax:423-634-6120
Practice Address - Street 1:1501 RIVERSIDE DR
Practice Address - Street 2:105
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37406-4309
Practice Address - Country:US
Practice Address - Phone:423-634-6966
Practice Address - Fax:423-634-6120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347E00000XTransportation ServicesTransportation Broker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNT000208Medicaid