Provider Demographics
NPI:1942658729
Name:SOUTHEAST REHAB LLC
Entity Type:Organization
Organization Name:SOUTHEAST REHAB LLC
Other - Org Name:SOUTHEAST REHABILITATION HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:M
Authorized Official - Last Name:WALDROP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-665-9950
Mailing Address - Street 1:903 BORGOGNONI DR
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:71653-1623
Mailing Address - Country:US
Mailing Address - Phone:318-665-9950
Mailing Address - Fax:318-665-0379
Practice Address - Street 1:903 BORGOGNONI DR
Practice Address - Street 2:
Practice Address - City:LAKE VILLAGE
Practice Address - State:AR
Practice Address - Zip Code:71653-1623
Practice Address - Country:US
Practice Address - Phone:870-265-4333
Practice Address - Fax:318-665-0379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-02
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty