Healthcare Provider Details

I. General information

NPI: 1952545055
Provider Name (Legal Business Name): SOUTHEASTERN HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2009
Last Update Date: 04/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161A JOHN JEFFERSON RD.
WILLIAMSBURG VA
23185-5640
US

IV. Provider business mailing address

161A JOHN JEFFERSON RD.
WILLIAMSBURG VA
23185-5640
US

V. Phone/Fax

Practice location:
  • Phone: 757-206-1167
  • Fax: 757-208-0639
Mailing address:
  • Phone: 757-206-1167
  • Fax: 757-208-0639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberHCO-09566
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License NumberHCO-09566
License Number StateVA

VIII. Authorized Official

Name: MR. ROBERT KOHAN
Title or Position: PRESIDENT/OWNER
Credential:
Phone: 757-206-1167