Provider Demographics
NPI:1336432087
Name:SOUTH EAST HOMES INC
Entity Type:Organization
Organization Name:SOUTH EAST HOMES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:JOHN PRIN
Authorized Official - Prefix:MS
Authorized Official - First Name:ABAH
Authorized Official - Middle Name:ABDUL
Authorized Official - Last Name:MOHAMED
Authorized Official - Suffix:
Authorized Official - Credentials:LADC
Authorized Official - Phone:612-702-7231
Mailing Address - Street 1:2542 17TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-4001
Mailing Address - Country:US
Mailing Address - Phone:612-702-7231
Mailing Address - Fax:
Practice Address - Street 1:2732 BLOOMINGTON AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55407-1146
Practice Address - Country:US
Practice Address - Phone:612-702-7231
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-26
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1062832-1-CDT324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1058560OtherDHS LICENSE