1750706453 NPI number — SOUTHEAST HEALTH CENTER OF REYNOLDS COUNTY, LLC

Table of content: (NPI 1750706453)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750706453 NPI number — SOUTHEAST HEALTH CENTER OF REYNOLDS COUNTY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEAST HEALTH CENTER OF REYNOLDS COUNTY, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
SOUTHEASTHEALTH FAMILY MEDICINE OF VAN BUREN
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750706453
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/04/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 HIGHWAY 21 N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELLINGTON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63638-9409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-663-2511
Provider Business Mailing Address Fax Number:
573-663-2815

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1009 BUSINESS HWY 60
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VAN BUREN
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63965-9103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-323-4812
Provider Business Practice Location Address Fax Number:
573-323-4850
Provider Enumeration Date:
03/04/2014

Additional Information

Authorized Official

Authorized Official Last Name:
HARRIS
Authorized Official First Name:
PAULA
Authorized Official Middle Name:
E
Authorized Official Title or Position:
VICE PRESIDENT REGIONAL OPERATIONS
Authorized Official Telephone Number:
573-778-0020

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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