1487632873 NPI number — SOUTHEASTERN SPECIALIST 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 1487632873 NPI number — SOUTHEASTERN SPECIALIST CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEASTERN SPECIALIST 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:
Provider Other Organization Name Type Code:
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:
1487632873
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
825 MAJESTIC COURT
Provider Second Line Business Mailing Address:
SUITE F
Provider Business Mailing Address City Name:
GASTONIA
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28054
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-867-8975
Provider Business Mailing Address Fax Number:
704-867-8353

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
825 MAJESTIC CT
Provider Second Line Business Practice Location Address:
SUITE F
Provider Business Practice Location Address City Name:
GASTONIA
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28054-5186
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-867-8975
Provider Business Practice Location Address Fax Number:
704-867-8353
Provider Enumeration Date:
01/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MILES
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
R.
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
704-867-8975

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  19633 , 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)

  • Identifier: 8958807 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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