Healthcare Provider Details

I. General information

NPI: 1679019491
Provider Name (Legal Business Name): SOUTHEAST MISSOURI HEALTH NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2017
Last Update Date: 11/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 PRAIRIE DRIVE
EAST PRAIRIE MO
63845
US

IV. Provider business mailing address

111 PRAIRIE DRIVE
EAST PRAIRIE MO
63845
US

V. Phone/Fax

Practice location:
  • Phone: 573-649-9311
  • Fax: 573-649-9331
Mailing address:
  • Phone: 573-649-9311
  • Fax: 573-649-9331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: SARA DEANE
Title or Position: CFO
Credential:
Phone: 573-313-2500