MEDICARE: SOUTHEASTERN RESIDENTIAL SERVICES OF NC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility	320600000X	NC

General Provider Information

NPI Number	:	1033359609
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHEASTERN RESIDENTIAL SERVICES OF NC

Provider Business Mailing Address
First Line	:	4811 RIVER STREAM WAY
Second Line	:	204
City	:	RALEIGH
State	:	NC
Zip	:	27616-6583
Country	:	US
Telephone Number	:	919-850-3368
Fax Number	:

Provider Business Practice Location Address
First Line	:	4811 RIVER STREAM WAY
Second Line	:	204
City	:	RALEIGH
State	:	NC
Zip	:	27616-6583
Country	:	US
Telephone Number	:	919-850-3368
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. ALANA ALICIA GEORGE
Credential	:
Telephone Number	:	919-850-3368

Provider Enumeration Date	:	02/23/2009
Last Update Date	:	02/23/2009

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