Healthcare Provider Details

I. General information

NPI: 1386802023
Provider Name (Legal Business Name): SOUTHEAST HEALTH CENTER OF STODDARD COUNTY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2008
Last Update Date: 01/13/2024
Certification Date: 01/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N ONE MILE RD
DEXTER MO
63841-1000
US

IV. Provider business mailing address

1200 N ONE MILE RD
DEXTER MO
63841-1000
US

V. Phone/Fax

Practice location:
  • Phone: 573-624-5566
  • Fax: 573-614-1966
Mailing address:
  • Phone: 573-624-5566
  • Fax: 573-614-1966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code275N00000X
TaxonomyMedicare Defined Swing Bed Hospital Unit
License Number464-6
License Number StateMO

VIII. Authorized Official

Name: KRISTA BERRY
Title or Position: CFO
Credential:
Phone: 573-331-6028