Basic Information
| Provider Information | |||||||||
| NPI: | 1639188626 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEAST THERAPY SERVICES INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 368 | ||||||||
| Address2: | |||||||||
| City: | OAKES | ||||||||
| State: | ND | ||||||||
| PostalCode: | 584740368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017423267 | ||||||||
| FaxNumber: | 7017423201 | ||||||||
| Practice Location | |||||||||
| Address1: | 69 HIGHWAY 13 W | ||||||||
| Address2: | |||||||||
| City: | GWINNER | ||||||||
| State: | ND | ||||||||
| PostalCode: | 580404127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7016782263 | ||||||||
| FaxNumber: | 7016832063 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2006 | ||||||||
| LastUpdateDate: | 08/07/2008 | ||||||||
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| AuthorizedOfficialLastName: | KELLY | ||||||||
| AuthorizedOfficialFirstName: | THERESA | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7017423267 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SOUTHEAST THERAPY SERVICES INC | ||||||||
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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 | CG3429 | 01 | ND | RAILROAD MEDICARE | OTHER | 1346005 | 01 | BCBS ND CLINIC NUMBER | OTHER | 51787 | 05 | ND | MEDICAID |