Healthcare Provider Details

I. General information

NPI: 1730192626
Provider Name (Legal Business Name): SOUTHEASTERN MEDICAL, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 09/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 SUNSET BLVD N
SUNSET BEACH NC
28468-4262
US

IV. Provider business mailing address

830 SUNSET BLVD N
SUNSET BEACH NC
28468-4262
US

V. Phone/Fax

Practice location:
  • Phone: 910-575-5750
  • Fax: 910-575-5751
Mailing address:
  • Phone: 910-575-5750
  • Fax: 910-575-5751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number10022
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number96-01376
License Number StateNC

VIII. Authorized Official

Name: DR. HENRY LEPORE
Title or Position: OWNER
Credential: MD
Phone: 910-575-5750