Provider Demographics
NPI:1679531461
Name:SOUTHEAST ADDICTION INSTITUTE AND LEARNING CENTER, INC
Entity Type:Organization
Organization Name:SOUTHEAST ADDICTION INSTITUTE AND LEARNING CENTER, INC
Other - Org Name:SAIL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:GLENN
Authorized Official - Last Name:AUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:CSAC, CCS
Authorized Official - Phone:704-561-0920
Mailing Address - Street 1:5601 EXECUTIVE CENTER DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28212-8841
Mailing Address - Country:US
Mailing Address - Phone:704-561-0920
Mailing Address - Fax:704-561-0851
Practice Address - Street 1:5601 EXECUTIVE CENTER DR
Practice Address - Street 2:SUITE 101
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-8841
Practice Address - Country:US
Practice Address - Phone:704-561-0920
Practice Address - Fax:704-561-0851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-060-587101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6005380Medicaid