Healthcare Provider Details

I. General information

NPI: 1780927871
Provider Name (Legal Business Name): SOUTHEAST HEALTH CENTER OF STODDARD COUNTY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2013
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2002 KANELL BLVD
POPLAR BLUFF MO
63901-4045
US

IV. Provider business mailing address

1200 N ONE MILE RD
DEXTER MO
63841-1015
US

V. Phone/Fax

Practice location:
  • Phone: 573-727-9130
  • Fax: 573-727-9128
Mailing address:
  • Phone: 573-614-1938
  • Fax: 573-624-8895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

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