Basic Information
| Provider Information | |||||||||
| NPI: | 1851628028 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEASTERN HOME CARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6281 TRI RIDGE BLVD STE 300 | ||||||||
| Address2: | |||||||||
| City: | LOVELAND | ||||||||
| State: | OH | ||||||||
| PostalCode: | 451408345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135760262 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1225 WOODLAWN AVE STE 113 | ||||||||
| Address2: | |||||||||
| City: | CAMBRIDGE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437253094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404255117 | ||||||||
| FaxNumber: | 7404255062 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2009 | ||||||||
| LastUpdateDate: | 07/20/2022 | ||||||||
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| AuthorizedOfficialLastName: | HAWKINS | ||||||||
| AuthorizedOfficialFirstName: | JACK | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP FINANCE, CFO | ||||||||
| AuthorizedOfficialTelephone: | 5135768478 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 3062635 | 05 | OH | MEDICAID |