Provider Demographics
NPI:1649460379
Name:SOUTH EAST ARKANSAS LAB & SCR SVCS
Entity type:Organization
Organization Name:SOUTH EAST ARKANSAS LAB & SCR SVCS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROSEN
Authorized Official - Suffix:
Authorized Official - Credentials:BS PD
Authorized Official - Phone:870-534-6699
Mailing Address - Street 1:201 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71601
Mailing Address - Country:US
Mailing Address - Phone:870-534-6699
Mailing Address - Fax:870-534-6699
Practice Address - Street 1:201 S MAIN ST
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71601
Practice Address - Country:US
Practice Address - Phone:870-534-6699
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTH EAST ARK. LABORATORY & SCR SVCS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-30
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR04D1059019291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR164955709Medicaid
AR164955709Medicaid
1649460379Medicare UPIN
E3824Medicare PIN