Healthcare Provider Details

I. General information

NPI: 1700959905
Provider Name (Legal Business Name): SOUTHEAST REHAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 11/07/2025
Certification Date: 11/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 BORGOGNONI DR
LAKE VILLAGE AR
71653-1623
US

IV. Provider business mailing address

905 BORGOGNONI DR
LAKE VILLAGE AR
71653-1623
US

V. Phone/Fax

Practice location:
  • Phone: 318-665-9950
  • 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 Code283X00000X
TaxonomyRehabilitation Hospital
License NumberAR4376
License Number StateAR

VIII. Authorized Official

Name: CATHERINE MARTIN WALDROP
Title or Position: ADMINISTRATOR/CEO
Credential: MED, LPC, NBCC
Phone: 318-665-9950