Provider Demographics
NPI:1770081077
Name:SOUTHEASTERN EYE CARE, PA
Entity type:Organization
Organization Name:SOUTHEASTERN EYE CARE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:MOUSER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-738-4856
Mailing Address - Street 1:106 FARM BROOK DR STE B
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-2178
Mailing Address - Country:US
Mailing Address - Phone:910-738-4856
Mailing Address - Fax:910-738-7999
Practice Address - Street 1:106 FARM BROOK DR
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2178
Practice Address - Country:US
Practice Address - Phone:910-738-4856
Practice Address - Fax:910-738-7999
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHEASTERN EYE CARE, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-02-01
Last Update Date:2018-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP16942225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2340498OtherMEDICARE