Basic Information
Provider Information | |||||||||
NPI: | 1215003215 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SOUTHEASTERN REGIONAL MEDICAL CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SOUTHEASTERN RECOVERY ALTERNATIVES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 300 W 27TH ST | ||||||||
Address2: |   | ||||||||
City: | LUMBERTON | ||||||||
State: | NC | ||||||||
PostalCode: | 283583075 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9106715000 | ||||||||
FaxNumber: | 9106715858 | ||||||||
Practice Location | |||||||||
Address1: | 705B WESLEY PINES RD | ||||||||
Address2: |   | ||||||||
City: | LUMBERTON | ||||||||
State: | NC | ||||||||
PostalCode: | 283582105 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9107381191 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/28/2006 | ||||||||
LastUpdateDate: | 03/15/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JOHNSON | ||||||||
AuthorizedOfficialFirstName: | C. | ||||||||
AuthorizedOfficialMiddleName: | THOMAS | ||||||||
AuthorizedOfficialTitleorPosition: | V. P. FINANCE | ||||||||
AuthorizedOfficialTelephone: | 9106715090 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: | III | ||||||||
AuthorizedOfficialCredential: | CPA | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | H0064 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
ID | Type | State | Issuer | Description | 6005521 | 05 | NC |   | MEDICAID |