Provider Demographics
NPI:1053660811
Name:MEMORIAL HOME CARE, INC.
Entity Type:Organization
Organization Name:MEMORIAL HOME CARE, INC.
Other - Org Name:FAMILY NURSING SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:CONRAD
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:574-647-8777
Mailing Address - Street 1:3355 DOUGLAS RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1781
Mailing Address - Country:US
Mailing Address - Phone:574-273-2273
Mailing Address - Fax:574-273-5605
Practice Address - Street 1:58025 COUNTY ROAD 9
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46517-2260
Practice Address - Country:US
Practice Address - Phone:574-266-3661
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-07
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12-005298-1251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100091080BMedicaid
IN100263690COtherWAIVER
IN100091080BMedicaid