Provider Demographics
NPI:1649499278
Name:SOUTHEASTERN REGIONAL MEDICAL CENTER
Entity type:Organization
Organization Name:SOUTHEASTERN REGIONAL MEDICAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:LARRY
Authorized Official - Last Name:PITTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MA,LCAS,CCS
Authorized Official - Phone:910-272-3030
Mailing Address - Street 1:705- B WESLEY PINE ROAD
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358
Mailing Address - Country:US
Mailing Address - Phone:910-272-3030
Mailing Address - Fax:
Practice Address - Street 1:107 DALLAS AVE
Practice Address - Street 2:
Practice Address - City:RED SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:28377-1849
Practice Address - Country:US
Practice Address - Phone:910-272-3030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300343P MAMedicaid
NC8300343Medicaid
NC8300343B MAMedicaid
NC8300343Medicaid