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General NPI Number Information
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NPI Number | 1144600875
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Entity Type | Organization
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Legal Business Name | SOUTHEAST HOSPICE, LLC,
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Dates
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Enumeration Date | 06/08/2015
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Last Update Date | 02/10/2017
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Provider Practice Location Address
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Address Line | 1203 GEORGE C. WILSON DRIVE SUITE A
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City | AUGUSTA
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State | GA
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Zip | 30909-4502
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Country | US
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Telephone | 706-364-3108
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Fax | 706-364-3315
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Provider Business Mailing Address
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Address Line | 1203 GEORGE C. WILSON DRIVE SUITE A
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City | AUGUSTA
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State | GA
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Zip | 30909-4502
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Country | US
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Telephone | 706-364-3108
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Fax | 706-364-3315
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | STUART PRATHER
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Credential |
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Telephone | 706-364-3108
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251G00000X
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Taxonomy Name | Community Based Hospice Care Agency
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License Number | 121-0416-H
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License Number State | GA
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