Provider Demographics
NPI:1952431645
Name:SOUTHEASTERN SPORTSMEDICINE
Entity Type:Organization
Organization Name:SOUTHEASTERN SPORTSMEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:AL
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-274-4555
Mailing Address - Street 1:81 EMMA DR
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28786-9006
Mailing Address - Country:US
Mailing Address - Phone:828-452-4476
Mailing Address - Fax:
Practice Address - Street 1:23 TURTLE CREEK DR
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28803-3152
Practice Address - Country:US
Practice Address - Phone:828-274-4555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC07392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty