MEDICARE: SOUTHEASTERN EYE CARE, PA

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	225100000X	Physical Therapist	P16942	NC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2340498	OTHER	NC	MEDICARE

General Provider Information

NPI Number	:	1770081077
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHEASTERN EYE CARE, PA

Provider Business Mailing Address
First Line	:	106 FARM BROOK DR STE B
Second Line	:
City	:	LUMBERTON
State	:	NC
Zip	:	28358-2178
Country	:	US
Telephone Number	:	910-738-4856
Fax Number	:	910-738-7999

Provider Business Practice Location Address
First Line	:	106 FARM BROOK DR
Second Line	:
City	:	LUMBERTON
State	:	NC
Zip	:	28358-2178
Country	:	US
Telephone Number	:	910-738-4856
Fax Number	:	910-738-7999

Authorized Official
Title or Position	:	MD, OWNER
Name	:	DR. TIMOTHY SCOTT MOUSER
Credential	:	MD
Telephone Number	:	910-738-4856

Provider Enumeration Date	:	02/01/2018
Last Update Date	:	02/01/2018

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