Provider Demographics
NPI:1457962797
Name:SOUTHEASTERN SUPPORT CARE SERVICES LLC
Entity Type:Organization
Organization Name:SOUTHEASTERN SUPPORT CARE SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-341-3592
Mailing Address - Street 1:3523 FULLER ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31907-2554
Mailing Address - Country:US
Mailing Address - Phone:706-341-3592
Mailing Address - Fax:
Practice Address - Street 1:3523 FULLER ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31907-2554
Practice Address - Country:US
Practice Address - Phone:706-341-3592
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services