Provider Demographics
NPI:1801891015
Name:SOUTHEAST HEALTH CENTER OF STODDARD COUNTY, LLC
Entity type:Organization
Organization Name:SOUTHEAST HEALTH CENTER OF STODDARD COUNTY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP REGIONAL OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-778-0020
Mailing Address - Street 1:1300 N ONE MILE RD
Mailing Address - Street 2:SUITE 7
Mailing Address - City:DEXTER
Mailing Address - State:MO
Mailing Address - Zip Code:63841-1042
Mailing Address - Country:US
Mailing Address - Phone:573-624-3511
Mailing Address - Fax:573-624-5839
Practice Address - Street 1:1300 N ONE MILE RD
Practice Address - Street 2:SUITE 7
Practice Address - City:DEXTER
Practice Address - State:MO
Practice Address - Zip Code:63841-1042
Practice Address - Country:US
Practice Address - Phone:573-624-3511
Practice Address - Fax:573-624-5839
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHEAST HEALTH CENTER OF STODDARD COUNTY, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-06-15
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO760251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO54OtherBLUECROSS/BLUESHIELD
MO580722601Medicaid
MO580722601Medicaid