Provider Demographics
NPI:1730117755
Name:SOUTHEAST CLINIC
Entity Type:Organization
Organization Name:SOUTHEAST CLINIC
Other - Org Name:JEFFERSON MANAGEMENT SERVICES, INC.D/B/A SOUTHEAST CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:HOLADAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-367-1413
Mailing Address - Street 1:PO BOX 1920
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:AR
Mailing Address - Zip Code:71657-1920
Mailing Address - Country:US
Mailing Address - Phone:870-367-1413
Mailing Address - Fax:870-367-0012
Practice Address - Street 1:750 H L ROSS DR
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655-5705
Practice Address - Country:US
Practice Address - Phone:870-367-1413
Practice Address - Fax:870-367-0012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE1635261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARF79730Medicare UPIN
AR5F468Medicare ID - Type Unspecified