1326275728 NPI number — SOUTHEASTERN REGIONAL MEDICAL CLINIC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326275728 NPI number — SOUTHEASTERN REGIONAL MEDICAL CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEASTERN REGIONAL MEDICAL CLINIC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SOUTHEASTERN MEDICAL CLINIC PARKTON
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326275728
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/23/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2600 N ELM ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LUMBERTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28358-3011
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-272-3051
Provider Business Mailing Address Fax Number:
910-738-3764

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 W.3RD ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PARKTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28371-0128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-858-3913
Provider Business Practice Location Address Fax Number:
910-738-3764
Provider Enumeration Date:
06/12/2009

Additional Information

Authorized Official

Authorized Official Last Name:
JOHNSON
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
T.
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
910-671-5090

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  H0064 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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