Healthcare Provider Details

I. General information

NPI: 1477928760
Provider Name (Legal Business Name): SOUTHEASTERN REGIONAL PHYSICIAN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2015
Last Update Date: 10/20/2020
Certification Date: 10/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W 27TH ST
LUMBERTON NC
28358-3021
US

IV. Provider business mailing address

2002 N CEDAR ST STE B
LUMBERTON NC
28358-3926
US

V. Phone/Fax

Practice location:
  • Phone: 910-272-9675
  • Fax: 910-272-9276
Mailing address:
  • Phone: 910-272-3048
  • Fax: 910-738-3764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. RAYMOND HENLEY
Title or Position: DIRECTOR
Credential:
Phone: 910-737-3147