Provider Demographics
NPI:1710047618
Name:SOUTHEAST HEALTH CENTER OF STODDARD COUNTY, LLC
Entity Type:Organization
Organization Name:SOUTHEAST HEALTH CENTER OF STODDARD COUNTY, LLC
Other - Org Name:SOUTHEASTHEALTH CHILDREN'S CLINIC OF DEXTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT REGIONAL OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:E
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-778-0020
Mailing Address - Street 1:PO BOX 368
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:MO
Mailing Address - Zip Code:63841-0368
Mailing Address - Country:US
Mailing Address - Phone:573-624-3165
Mailing Address - Fax:573-624-3157
Practice Address - Street 1:1300 N ONE MILE RD
Practice Address - Street 2:SUITE 2
Practice Address - City:DEXTER
Practice Address - State:MO
Practice Address - Zip Code:63841-1042
Practice Address - Country:US
Practice Address - Phone:573-624-7662
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHEAST HEALTH CENTER OF STODDARD COUNTY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-11
Last Update Date:2013-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO595969007Medicaid
MO595969007Medicaid
MO268546Medicare Oscar/Certification