Healthcare Provider Details

I. General information

NPI: 1043495377
Provider Name (Legal Business Name): SOUTH EASTERN MEDICAL SUPLIES,INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2008
Last Update Date: 04/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1307 E MILLBROOK RD SUITE C-23
RALEIGH NC
27609-5476
US

IV. Provider business mailing address

1307 E MILLBROOK RD SUITE C-23
RALEIGH NC
27609-5476
US

V. Phone/Fax

Practice location:
  • Phone: 919-341-4468
  • Fax: 919-341-2378
Mailing address:
  • Phone: 919-341-4468
  • Fax: 919-341-2378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number01375
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number01375
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number01375
License Number StateNC

VIII. Authorized Official

Name: EZUMA E ASI
Title or Position: DIRECTOR
Credential: RN
Phone: 919-341-4468