Provider Demographics
NPI:1700182029
Name:SOUTHEAST DIAGNOSTICS LLC
Entity Type:Organization
Organization Name:SOUTHEAST DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MILTON
Authorized Official - Middle Name:A
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:912-548-1735
Mailing Address - Street 1:2002 TEBEAU ST
Mailing Address - Street 2:
Mailing Address - City:WAYCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:31501-6359
Mailing Address - Country:US
Mailing Address - Phone:912-548-1735
Mailing Address - Fax:912-548-1736
Practice Address - Street 1:2002 TEBEAU ST
Practice Address - Street 2:
Practice Address - City:WAYCROSS
Practice Address - State:GA
Practice Address - Zip Code:31501-6359
Practice Address - Country:US
Practice Address - Phone:912-548-1735
Practice Address - Fax:912-548-1736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-03
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory