Healthcare Provider Details

I. General information

NPI: 1477780476
Provider Name (Legal Business Name): SOUTHEASTERN REGIONAL PHYSICIAN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2009
Last Update Date: 06/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9928 N. W. R. LATHAN ST.
CLARKTON NC
28433
US

IV. Provider business mailing address

2600 N ELM ST
LUMBERTON NC
28358-3011
US

V. Phone/Fax

Practice location:
  • Phone: 910-647-1503
  • Fax: 910-738-3764
Mailing address:
  • Phone: 910-272-3051
  • Fax: 910-737-3764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberH0064
License Number StateNC

VIII. Authorized Official

Name: CHARLES T. JOHNSON III
Title or Position: CFO
Credential:
Phone: 910-671-5090