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General NPI Number Information
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NPI Number | 1093389231
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Entity Type | Organization
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Legal Business Name | SOUTHEASTERN REGIONAL PHYSICIAN SERVICES
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Dates
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Enumeration Date | 05/13/2021
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Last Update Date | 04/28/2025
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Provider Practice Location Address
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Address Line | 1249 CHICKEN FOOT RD STE C
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City | HOPE MILLS
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State | NC
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Zip | 28348-7525
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Country | US
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Telephone | 910-779-1967
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Fax | 910-779-1968
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Provider Business Mailing Address
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Address Line | PO BOX 749193
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City | ATLANTA
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State | GA
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Zip | 30374-9193
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Country | US
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Telephone | 984-974-4372
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Fax |
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Authorized Official
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Title or Position | CRO
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Name | CHARLES THOMAS JOHNSON
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Credential |
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Telephone | 910-671-5083
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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