Provider Demographics
NPI:1245681048
Name:SOUTHEASTERN INTEGRATED CARE
Entity type:Organization
Organization Name:SOUTHEASTERN INTEGRATED CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:Z
Authorized Official - Last Name:MORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-294-1075
Mailing Address - Street 1:68 THREE HUNTS DR STE A
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:NC
Mailing Address - Zip Code:28372-7319
Mailing Address - Country:US
Mailing Address - Phone:910-522-0408
Mailing Address - Fax:704-931-9199
Practice Address - Street 1:68 THREE HUNTS DR STE A
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:NC
Practice Address - Zip Code:28372-7319
Practice Address - Country:US
Practice Address - Phone:910-522-0408
Practice Address - Fax:704-931-9199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-23
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care