Healthcare Provider Details

I. General information

NPI: 1124026547
Provider Name (Legal Business Name): SOUTHEASTERN HEALTH PLUS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2005
Last Update Date: 06/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 48TH AVE N STE C
MYRTLE BEACH SC
29577-5427
US

IV. Provider business mailing address

1301 48TH AVE N STE C
MYRTLE BEACH SC
29577-5427
US

V. Phone/Fax

Practice location:
  • Phone: 843-839-1374
  • Fax: 877-408-8192
Mailing address:
  • Phone: 843-839-1374
  • Fax: 877-408-8192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierDME925
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name: MR. JOHN J MORAN
Title or Position: CHIEF FINANCIAL OFFI
Credential:
Phone: 843-939-1374