Healthcare Provider Details

I. General information

NPI: 1194358523
Provider Name (Legal Business Name): SOUTHEAST REHAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2020
Last Update Date: 03/24/2023
Certification Date: 03/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 S HIGHWAY 65 82
LAKE VILLAGE AR
71653-1743
US

IV. Provider business mailing address

PO BOX 743
LAKE VILLAGE AR
71653-0743
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License Number
License Number State

VIII. Authorized Official

Name: CATHERINE MARTIN WALDROP
Title or Position: ADMINISTRATOR
Credential:
Phone: 318-665-9950