Healthcare Provider Details

I. General information

NPI: 1689036477
Provider Name (Legal Business Name): SOUTHEASTERN DIAGNOSTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 03/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

86261 HIGHWAY 9
ASHLAND AL
36251-7823
US

IV. Provider business mailing address

109 FOOTHILLS PKWY SUITE 113
CHELSEA AL
35043-8235
US

V. Phone/Fax

Practice location:
  • Phone: 205-613-5255
  • Fax:
Mailing address:
  • Phone: 205-619-5255
  • Fax: 205-618-9706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code246XS1301X
TaxonomySonography Specialist/Technologist Cardiovascular
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIAM CARL WAINSCOTT II
Title or Position: CFO
Credential:
Phone: 205-613-5255