Provider Demographics
NPI:1811492853
Name:SOUTHEASTERN PSYCHIATRIC PROVIDERS, LLC
Entity type:Organization
Organization Name:SOUTHEASTERN PSYCHIATRIC PROVIDERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/AUTHORIZED
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DONALDSON
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:408-364-6160
Mailing Address - Street 1:PO BOX 3516
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28406-0516
Mailing Address - Country:US
Mailing Address - Phone:408-364-6160
Mailing Address - Fax:
Practice Address - Street 1:2050 MERCANTILE DR APT C9
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451-4053
Practice Address - Country:US
Practice Address - Phone:910-370-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty