Provider Demographics
NPI:1841213196
Name:SOUTHEASTERN OCULARISTS, INC.
Entity Type:Organization
Organization Name:SOUTHEASTERN OCULARISTS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERLITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-510-9292
Mailing Address - Street 1:8426 MEDICAL PLAZA DR
Mailing Address - Street 2:SUITE 500
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-9746
Mailing Address - Country:US
Mailing Address - Phone:704-510-9292
Mailing Address - Fax:704-510-9881
Practice Address - Street 1:1300 HOSPITAL DR
Practice Address - Street 2:SUITE 260
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3261
Practice Address - Country:US
Practice Address - Phone:843-884-7113
Practice Address - Fax:704-510-9881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDE2724Medicaid