MEDICARE: SOUTH EAST HOMES INC

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	324500000X	Substance Abuse Rehabilitation Facility	1062832-1-CDT	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1058560	OTHER	MN	DHS LICENSE

General Provider Information

NPI Number	:	1336432087
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH EAST HOMES INC

Provider Business Mailing Address
First Line	:	2542 17TH AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55404-4001
Country	:	US
Telephone Number	:	612-702-7231
Fax Number	:

Provider Business Practice Location Address
First Line	:	2732 BLOOMINGTON AVE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-1146
Country	:	US
Telephone Number	:	612-702-7231
Fax Number	:

Authorized Official
Title or Position	:	JOHN PRIN
Name	:	MS. ABAH ABDUL MOHAMED
Credential	:	LADC
Telephone Number	:	612-702-7231

Provider Enumeration Date	:	05/26/2011
Last Update Date	:	08/17/2012

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Directions to “SOUTH EAST HOMES INC ” Practice Location

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