Healthcare Provider Details

I. General information

NPI: 1801990825
Provider Name (Legal Business Name): SOUTHEAST HEALTH CENTER OF STODDARD COUNTY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2006
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:
Mailing address:
  • Phone: 573-624-5566
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number464-5
License Number StateMO

VIII. Authorized Official

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