Provider Demographics
NPI:1922093947
Name:SOUTHEASTERN UNITED CARE LLC
Entity Type:Organization
Organization Name:SOUTHEASTERN UNITED CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AGENCY DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DEMETRUS
Authorized Official - Middle Name:
Authorized Official - Last Name:LOCKLEAR
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:910-521-9557
Mailing Address - Street 1:PO BOX 159
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:NC
Mailing Address - Zip Code:28372-0159
Mailing Address - Country:US
Mailing Address - Phone:910-521-9557
Mailing Address - Fax:910-521-0077
Practice Address - Street 1:30 DRAKES BRANCH DRIVE
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:NC
Practice Address - Zip Code:28372-7325
Practice Address - Country:US
Practice Address - Phone:910-521-9557
Practice Address - Fax:910-521-0077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-15
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC 2923251E00000X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3408256Medicaid
NC8301697Medicaid
NC6006401Medicaid
NC6601239Medicaid
NC8301697BMedicaid
NC8301697GMedicaid