Provider Demographics
NPI:1952477655
Name:SOUTHEASTERN REGIOINAL MEDICAL CENTER
Entity Type:Organization
Organization Name:SOUTHEASTERN REGIOINAL MEDICAL CENTER
Other - Org Name:SOUTHEASTERN HOME CARE NUTRIENTS
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 III
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:910-671-5090
Mailing Address - Street 1:2002 N CEDAR ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-3926
Mailing Address - Country:US
Mailing Address - Phone:910-671-5600
Mailing Address - Fax:910-739-3551
Practice Address - Street 1:2002 N CEDAR ST
Practice Address - Street 2:SUITE B
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-3926
Practice Address - Country:US
Practice Address - Phone:910-671-5600
Practice Address - Fax:910-739-3551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCH0064251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6800127Medicaid