Provider Demographics
NPI:1104517424
Name:LSP SOUTHEAST, LLC
Entity type:Organization
Organization Name:LSP SOUTHEAST, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:ALYSSA
Authorized Official - Middle Name:
Authorized Official - Last Name:ZELKOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-297-2184
Mailing Address - Street 1:290 HANCOCK SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:BAY ST LOUIS
Mailing Address - State:MS
Mailing Address - Zip Code:39520-1634
Mailing Address - Country:US
Mailing Address - Phone:480-297-2184
Mailing Address - Fax:
Practice Address - Street 1:290 HANCOCK SQUARE DR
Practice Address - Street 2:
Practice Address - City:BAY ST LOUIS
Practice Address - State:MS
Practice Address - Zip Code:39520-1634
Practice Address - Country:US
Practice Address - Phone:480-297-2184
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-17
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory