Healthcare Provider Details

I. General information

NPI: 1710047618
Provider Name (Legal Business Name): SOUTHEAST HEALTH CENTER OF STODDARD COUNTY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 10/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 N ONE MILE RD SUITE 2
DEXTER MO
63841-1042
US

IV. Provider business mailing address

PO BOX 368
DEXTER MO
63841-0368
US

V. Phone/Fax

Practice location:
  • Phone: 573-624-7662
  • Fax:
Mailing address:
  • Phone: 573-624-3165
  • Fax: 573-624-3157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateMO

VIII. Authorized Official

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