Organization
STATE OF MISSOURI
Active
Parent organization
STATE OF MISSOURI
Other names
Southeast Missouri Residential Services-Poplar Bluff Prof Grp
Organization subpart
Yes
Provider details
NPI number
Legal business name
STATE OF MISSOURI
Authorized official
MOLLY JANE BOECKMANN (DIRECTOR OF ADMINISTRATIVE SERVICES)
(573) 751-4055
Entity
Organization
Contact information
Practice address
2351 KANELL BLVD, POPLAR BLUFF, MO 63901-4035
(573) 840-9370
(573) 840-9373
Mailing address
PO BOX 687, JEFFERSON CITY, MO 65102-0687
(573) 751-3398
(573) 526-4560
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
—
—
207Q00000X
Family Medicine Physician
Primary
—
—
Other
Enumeration date
08/25/2011
Last updated
10/15/2020
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