Healthcare Provider Details

I. General information

NPI: 1063779114
Provider Name (Legal Business Name): SOUTHEASTERN REGIONAL MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2012
Last Update Date: 04/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2934 N. EL M ST. SUITE B
LUMBERTON NC
28358-2981
US

IV. Provider business mailing address

PO BOX 890860
CHARLOTTE NC
28289-0860
US

V. Phone/Fax

Practice location:
  • Phone: 910-272-1175
  • Fax: 910-272-1176
Mailing address:
  • Phone: 910-671-5290
  • Fax: 910-671-8512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License NumberH0064
License Number StateNC

VIII. Authorized Official

Name: CHARLES THOMAS JOHNSON III
Title or Position: VP
Credential:
Phone: 910-671-5090