Basic Information
| Provider Information | |||||||||
| NPI: | 1356350342 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHEAST THERAPY SERVICES INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 368 | ||||||||
| Address2: | |||||||||
| City: | OAKES | ||||||||
| State: | ND | ||||||||
| PostalCode: | 584740368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017423267 | ||||||||
| FaxNumber: | 7017423201 | ||||||||
| Practice Location | |||||||||
| Address1: | 102 10TH AVENUE WEST | ||||||||
| Address2: | |||||||||
| City: | LISBON | ||||||||
| State: | ND | ||||||||
| PostalCode: | 580541097 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7016832214 | ||||||||
| FaxNumber: | 7016832130 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2006 | ||||||||
| LastUpdateDate: | 12/02/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KELLY | ||||||||
| AuthorizedOfficialFirstName: | THERESA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7017423267 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHEAST THERAPY SERVICES INC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2000X | Y | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy |
ID Information
| ID | Type | State | Issuer | Description | 51787 | 05 | ND | MEDICAID | 1346002 | 01 | ND | BCBS ND CLINIC# | OTHER | CG3429 | 01 | ND | RAILROAD MEDICARE | OTHER |