Provider Demographics
NPI:1902328727
Name:SOUTHEAST IMAGING, LLC
Entity Type:Organization
Organization Name:SOUTHEAST IMAGING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMIAH
Authorized Official - Middle Name:AARON
Authorized Official - Last Name:JANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-249-7672
Mailing Address - Street 1:3330 NW 56TH ST.
Mailing Address - Street 2:SUITE 206
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112
Mailing Address - Country:US
Mailing Address - Phone:405-945-4710
Mailing Address - Fax:405-945-4751
Practice Address - Street 1:111 FOREST AVE.
Practice Address - Street 2:SUITE C
Practice Address - City:EUFAULA
Practice Address - State:OK
Practice Address - Zip Code:74432
Practice Address - Country:US
Practice Address - Phone:405-945-4710
Practice Address - Fax:405-945-4751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-13
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK261QR0200X
293D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No293D00000XLaboratoriesPhysiological Laboratory