MEDICARE: SOUTHEASTERN HEALTHCARE OF JACKSONVILLE, PC

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	111N00000X	Chiropractor	3421	NC

General Provider Information

NPI Number	:	1316090889
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHEASTERN HEALTHCARE OF JACKSONVILLE, PC

Provider Business Mailing Address
First Line	:	2595 S 17TH ST
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28401-7748
Country	:	US
Telephone Number	:	910-791-2788
Fax Number	:

Provider Business Practice Location Address
First Line	:	431 WESTERN BLVD
Second Line	:	SUITE E
City	:	JACKSONVILLE
State	:	NC
Zip	:	28546-6823
Country	:	US
Telephone Number	:	910-355-6000
Fax Number	:	910-355-7533

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. ELIZA R. GRAY
Credential	:
Telephone Number	:	910-791-2788

Provider Enumeration Date	:	01/19/2007
Last Update Date	:	10/01/2007

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