NPIMap

Organization Active NPI

Southeast Rehab LLC

  • Rural Health Clinic/Center
  • Lake Village, AR
National Provider Identifier
1194358523
Registry record updated Mar 24, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
SOUTHEAST REHAB LLC
Practice address
608 S Highway 65 82
Lake Village, AR 71653-1743
Phone
(870) 265-4333
Fax
(318) 665-9950
NPI assigned
Feb 13, 2020
Organization subpart
Yes
Parent organization
SOUTHEAST REHAB LLCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Mar 24, 2023

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Catherine Martin Waldrop
Title
Administrator
Phone
(318) 665-9950

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary
Rehabilitation Hospital 283X00000X

Addresses

Primary practice location

608 S Highway 65 82
Lake Village, AR 71653-1743

Mailing address

PO Box 743
Lake Village, AR 71653-0743
Phone (318) 665-9950

Other names 1

  • Southeast Rural Health Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AR

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20200311000979 AR Part A Provider - Rural Health Clinic 6709884604 Practice locations: Lake Village, AR

Rural health clinic certification: CCN 048523

Legal name
SOUTHEAST REHAB LLC.
Doing business as
SOUTHEAST RURAL HEALTH CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
May 21, 2020
Last certification
May 21, 2020
Ownership / control type
1B
Organization structure
LLCProprietary
Incorporated
Nov 1, 2006 in AR
Enrollment address
608 S Highway 6582
Lake Village, AR 71653-1743
Related CCNs
043034

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 2

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

National Provider Directory

National Provider Directory
Tax ID family
Southeast Rehab LLC4 organizations share this tax ID, including this one
Part of
Southeast Rehab LLC

Other organizations with this tax ID 3

Organizations that report the same tax identification number in the National Provider Directory.

Locations

608 S Highway 65 82
Ste C
Lake Village, AR 71653
Phone (870) 265-9810

Ownership & related parties

All disclosed owners & managing parties 10

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
John M Lipka Individual 5% Or Greater Direct Ownership Interest Mar 1, 2020
Diane Carothers Individual 5% Or Greater Direct Ownership Interest Mar 1, 2020
James C Wright Individual 5% Or Greater Direct Ownership Interest Mar 1, 2020
Allen L Spires Individual 5% Or Greater Direct Ownership Interest Mar 1, 2020
John R Russell Individual 5% Or Greater Direct Ownership Interest Mar 1, 2020
Corporate Officer Nov 1, 2006 12.12%
Catherine M Waldrop Individual 5% Or Greater Direct Ownership Interest Mar 1, 2020
Corporate OfficerAdministrator Nov 1, 2006 9.23%
W-2 Managing EmployeeAdministrator Nov 1, 2018 9.23%
John P Burge Individual 5% Or Greater Direct Ownership Interest Mar 1, 2020
Monie Melinda Wright Individual 5% Or Greater Direct Ownership Interest Mar 1, 2020
Linda Haddock Individual General Partnership Interest Oct 29, 2024 5.38%
Stacy Noble Individual 5% Or Greater Direct Ownership Interest Mar 1, 2020

Owners & managing parties with NPI records 5

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 1

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Southeast Rehabilitation HospitalLake Village, AR, CCN 043034 Hospital Operational/Managerial Control (100%) Nov 1, 2006

Owned or controlled facilities with NPI records 1

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Practitioners 3

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1581552000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1679616000000",
    "number": "1194358523",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 743",
            "city": "LAKE VILLAGE",
            "state": "AR",
            "postal_code": "716530743",
            "telephone_number": "318-665-9950",
            "fax_number": "318-665-0379"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "608 S HIGHWAY 65 82",
            "city": "LAKE VILLAGE",
            "state": "AR",
            "postal_code": "716531743",
            "telephone_number": "870-265-4333",
            "fax_number": "318-665-9950"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHEAST REHAB LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "SOUTHEAST REHAB LLC",
        "enumeration_date": "2020-02-13",
        "last_updated": "2023-03-24",
        "certification_date": "2023-03-24",
        "status": "A",
        "authorized_official_last_name": "WALDROP",
        "authorized_official_first_name": "CATHERINE",
        "authorized_official_middle_name": "MARTIN",
        "authorized_official_title_or_position": "ADMINISTRATOR",
        "authorized_official_telephone_number": "318-665-9950"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "283X00000X",
            "taxonomy_group": "",
            "desc": "Rehabilitation Hospital",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Southeast Rural Health Clinic",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Southeast Rural Health Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Lake Village, AR

Sources for this page

Verify at the official NPI Registry.