Healthcare Provider Details

I. General information

NPI: 1912358110
Provider Name (Legal Business Name): SOUTHEAST SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2016
Last Update Date: 06/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1983 LAKE SHADOW WAY
SUWANEE GA
30024-4311
US

IV. Provider business mailing address

1983 LAKE SHADOW WAY
SUWANEE GA
30024-4311
US

V. Phone/Fax

Practice location:
  • Phone: 678-908-5919
  • Fax: 770-822-2337
Mailing address:
  • Phone: 678-908-5919
  • Fax: 770-822-2337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number067-R-1279
License Number StateGA

VIII. Authorized Official

Name: MR. SALIM KABA
Title or Position: ADMINISTRATOR
Credential:
Phone: 678-908-5919