MEDICARE: SOUTHEAST COMMUNITY SERVICE AGENCY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	347E00000X	Transportation Broker

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1639215171
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHEAST COMMUNITY SERVICE AGENCY

Provider Business Mailing Address
First Line	:	1501 RIVERSIDE DR
Second Line	:	105
City	:	CHATTANOOGA
State	:	TN
Zip	:	37406-4309
Country	:	US
Telephone Number	:	423-634-6966
Fax Number	:	423-634-6120

Provider Business Practice Location Address
First Line	:	1501 RIVERSIDE DR
Second Line	:	105
City	:	CHATTANOOGA
State	:	TN
Zip	:	37406-4309
Country	:	US
Telephone Number	:	423-634-6966
Fax Number	:	423-634-6120

Authorized Official
Title or Position	:	COORDINATOR
Name	:	MS. RESHONDA SHANAY GOINS
Credential	:
Telephone Number	:	423-634-6966

Provider Enumeration Date	:	01/30/2007
Last Update Date	:	07/13/2007

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