Provider Demographics
NPI:1689741589
Name:SOUTHEASTERN REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:SOUTHEASTERN REGIONAL MEDICAL CENTER
Other - Org Name:WOODHAVEN NURSING & ALZHEIMER'S CARE CENTER-ICF
Other - Org Type:Doing Business As
Authorized Official - Title/Position:V. P. FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:C.
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:III
Authorized Official - Credentials:CPA
Authorized Official - Phone:910-671-5090
Mailing Address - Street 1:1150 PINE RUN DR
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-2118
Mailing Address - Country:US
Mailing Address - Phone:910-671-5703
Mailing Address - Fax:
Practice Address - Street 1:1150 PINE RUN DR
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2118
Practice Address - Country:US
Practice Address - Phone:910-671-5703
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCH0064313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3416431Medicaid