Provider Demographics
NPI:1861573198
Name:SOUTH EAST EYECARE
Entity type:Organization
Organization Name:SOUTH EAST EYECARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEWANNA
Authorized Official - Middle Name:K
Authorized Official - Last Name:STAUP
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:256-534-3900
Mailing Address - Street 1:6838 HIGHWAY 431 S
Mailing Address - Street 2:SUITE A
Mailing Address - City:OWENS CROSS ROADS
Mailing Address - State:AL
Mailing Address - Zip Code:35763-7200
Mailing Address - Country:US
Mailing Address - Phone:256-534-3900
Mailing Address - Fax:256-534-6994
Practice Address - Street 1:6838 HIGHWAY 431 S
Practice Address - Street 2:SUITE A
Practice Address - City:OWENS CROSS ROADS
Practice Address - State:AL
Practice Address - Zip Code:35763-7200
Practice Address - Country:US
Practice Address - Phone:256-534-3900
Practice Address - Fax:256-534-6994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL510G700063Medicare PIN
AL1222740001Medicare NSC