Provider Demographics
NPI:1700959905
Name:SOUTHEAST REHAB LLC
Entity Type:Organization
Organization Name:SOUTHEAST REHAB LLC
Other - Org Name:SOUTHEAST REHABILITATION HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR/CEO
Authorized Official - Prefix:
Authorized Official - First Name:CATHERINE
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:WALDROP
Authorized Official - Suffix:
Authorized Official - Credentials:MED, LPC, NBCC
Authorized Official - Phone:318-665-9950
Mailing Address - Street 1:903 BORGOGNONI DR
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:71653-1623
Mailing Address - Country:US
Mailing Address - Phone:318-665-9950
Mailing Address - Fax:318-665-0379
Practice Address - Street 1:903 BORGOGNONI DR
Practice Address - Street 2:
Practice Address - City:LAKE VILLAGE
Practice Address - State:AR
Practice Address - Zip Code:71653-1623
Practice Address - Country:US
Practice Address - Phone:318-665-9950
Practice Address - Fax:318-665-0379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR4376283X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283X00000XHospitalsRehabilitation Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR163180526Medicaid
AR043034Medicare Oscar/Certification