Healthcare Provider Details

I. General information

NPI: 1467406041
Provider Name (Legal Business Name): SOUTHEASTERN ORTHOPAEDICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 N NEW HOPE RD SUITE A
GASTONIA NC
28054
US

IV. Provider business mailing address

760 N NEW HOPE RD SUITE A
GASTONIA NC
28054
US

V. Phone/Fax

Practice location:
  • Phone: 704-866-8976
  • Fax: 704-866-8680
Mailing address:
  • Phone: 704-866-8976
  • Fax: 704-866-8680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number320
License Number StateNC

VIII. Authorized Official

Name: DR. DANIEL SCOTT MCMAHAN
Title or Position: ADMINISTRATOR
Credential:
Phone: 704-866-8976