Provider Demographics
NPI:1386802023
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 1:1200 N ONE MILE RD
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:MO
Mailing Address - Zip Code:63841-1000
Mailing Address - Country:US
Mailing Address - Phone:573-624-5566
Mailing Address - Fax:573-614-1966
Practice Address - Street 1:1200 N ONE MILE RD
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:MO
Practice Address - Zip Code:63841-1000
Practice Address - Country:US
Practice Address - Phone:573-624-5566
Practice Address - Fax:573-614-1966
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHEAST HEALTH CENTER OF STODDARD COUNTY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-29
Last Update Date:2024-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO464-6275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO26U160Medicare Oscar/Certification