Basic Information
| Provider Information | |||||||||
| NPI: | 1205259546 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEASTERN REGIONAL PHYSICIAN SERVICES | ||||||||
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| OtherOrganizationName: | SOUTHEASTERN WEIGHT LOSS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2600 N ELM ST | ||||||||
| Address2: | |||||||||
| City: | LUMBERTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283583011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102723051 | ||||||||
| FaxNumber: | 9107383764 | ||||||||
| Practice Location | |||||||||
| Address1: | 2934 N ELM ST | ||||||||
| Address2: | SUITE F | ||||||||
| City: | LUMBERTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283582986 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9106080307 | ||||||||
| FaxNumber: | 9106082112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2014 | ||||||||
| LastUpdateDate: | 01/22/2014 | ||||||||
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| AuthorizedOfficialLastName: | BRITT | ||||||||
| AuthorizedOfficialFirstName: | FORDHAM | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9106715026 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | H0064 | NC | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.