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General NPI Number Information
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NPI Number | 1942658729
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Entity Type | Organization
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Legal Business Name | SOUTHEAST REHAB LLC
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Dates
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Enumeration Date | 06/02/2016
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Last Update Date | 06/28/2019
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Provider Practice Location Address
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Address Line | 903 BORGOGNONI DR
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City | LAKE VILLAGE
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State | AR
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Zip | 71653-1623
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Country | US
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Telephone | 870-265-4333
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Fax | 318-665-0379
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Provider Business Mailing Address
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Address Line | 903 BORGOGNONI DR
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City | LAKE VILLAGE
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State | AR
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Zip | 71653-1623
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Country | US
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Telephone | 318-665-9950
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Fax | 318-665-0379
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Authorized Official
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Title or Position | CHAIRMAN
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Name | CATHY M WALDROP
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Credential |
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Telephone | 318-665-9950
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 207QA0505X
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Taxonomy Name | Adult Medicine Physician
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License Number |
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License Number State |
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