Healthcare Provider Details

I. General information

NPI: 1568524437
Provider Name (Legal Business Name): SOUTHEAST HEALTH CENTER OF STODDARD COUNTY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 09/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N ONE MILE RD
DEXTER MO
63841-1000
US

IV. Provider business mailing address

PO BOX 368
DEXTER MO
63841
US

V. Phone/Fax

Practice location:
  • Phone: 573-624-7575
  • Fax:
Mailing address:
  • Phone: 573-624-3165
  • Fax: 573-624-3157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: PAULA E HARRIS
Title or Position: VICE PRESIDENT REGIONAL OPERATIONS
Credential:
Phone: 573-778-0020