Healthcare Provider Details

I. General information

NPI: 1275576654
Provider Name (Legal Business Name): POPLAR BLUFF REGIONAL MEDICAL CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 04/20/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 E HARBIN AVE
PUXICO MO
63960-9104
US

IV. Provider business mailing address

130 E HARBIN AVE
PUXICO MO
63960-9104
US

V. Phone/Fax

Practice location:
  • Phone: 573-222-3556
  • Fax:
Mailing address:
  • Phone: 573-222-3556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: PAULA LALOR
Title or Position: DIRECTOR/DELEGATED OFFICIAL
Credential:
Phone: 629-215-3953