Healthcare Provider Details

I. General information

NPI: 1326036138
Provider Name (Legal Business Name): SOUTHEASTERN INTEGRATED CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 02/27/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 FARM BROOK DR
LUMBERTON NC
28358-2179
US

IV. Provider business mailing address

PO BOX 1572
LUMBERTON NC
28359-1572
US

V. Phone/Fax

Practice location:
  • Phone: 910-738-7789
  • Fax: 910-738-7599
Mailing address:
  • Phone: 910-738-7789
  • Fax: 910-738-7599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateNC

VIII. Authorized Official

Name: NIKKIA DAY
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 704-467-8799