Provider Demographics
NPI:1174747026
Name:SOUTHEASTERN MEDICAL LABORATORY, INC
Entity type:Organization
Organization Name:SOUTHEASTERN MEDICAL LABORATORY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICKY
Authorized Official - Middle Name:L
Authorized Official - Last Name:JUDGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-423-6791
Mailing Address - Street 1:PO BOX 399
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74502-0399
Mailing Address - Country:US
Mailing Address - Phone:918-423-6791
Mailing Address - Fax:918-423-1603
Practice Address - Street 1:716 E WYANDOTTE AVE
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-5428
Practice Address - Country:US
Practice Address - Phone:918-423-6791
Practice Address - Fax:918-423-1603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory