Healthcare Provider Details

I. General information

NPI: 1942658729
Provider Name (Legal Business Name): SOUTHEAST REHAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2016
Last Update Date: 06/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

903 BORGOGNONI DR
LAKE VILLAGE AR
71653-1623
US

IV. Provider business mailing address

903 BORGOGNONI DR
LAKE VILLAGE AR
71653-1623
US

V. Phone/Fax

Practice location:
  • Phone: 870-265-4333
  • Fax: 318-665-0379
Mailing address:
  • Phone: 318-665-9950
  • Fax: 318-665-0379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CATHY M WALDROP
Title or Position: CHAIRMAN
Credential:
Phone: 318-665-9950