=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306888151
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHEASTERN HEALTH OF PENNSYLVANIA, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 PLAZA DR
-----------------------------------------------------
City | DOWNINGTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19335-5301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-269-9876
-----------------------------------------------------
Fax | 610-269-9566
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 PLAZA DR
-----------------------------------------------------
City | DOWNINGTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19335-5301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-269-9876
-----------------------------------------------------
Fax | 610-269-9566
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT OF FINANCE
-----------------------------------------------------
Name | MR. WILLIAM BENJAMIN DAVIS
-----------------------------------------------------
Credential | MBA
-----------------------------------------------------
Telephone | 215-788-3900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 747205
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------