Provider Demographics
NPI:1316240096
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:CFO
Authorized Official - Prefix:
Authorized Official - First Name:KRISTA
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-331-6028
Mailing Address - Street 1:500 N DOUGLASS ST
Mailing Address - Street 2:
Mailing Address - City:MALDEN
Mailing Address - State:MO
Mailing Address - Zip Code:63863-1506
Mailing Address - Country:US
Mailing Address - Phone:573-276-2221
Mailing Address - Fax:
Practice Address - Street 1:500 N DOUGLASS ST
Practice Address - Street 2:
Practice Address - City:MALDEN
Practice Address - State:MO
Practice Address - Zip Code:63863-1506
Practice Address - Country:US
Practice Address - Phone:573-276-2221
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-17
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1316240096Medicaid
MO1316240096Medicaid