Provider Demographics
NPI:1134109713
Name:CITIZENS MEMORIAL HEALTH CARE FOUNDATION
Entity Type:Organization
Organization Name:CITIZENS MEMORIAL HEALTH CARE FOUNDATION
Other - Org Name:LAKE STOCKTON HEALTHCARE FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTELLO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-276-5126
Mailing Address - Street 1:PO BOX 945
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:MO
Mailing Address - Zip Code:65785-0945
Mailing Address - Country:US
Mailing Address - Phone:417-276-5126
Mailing Address - Fax:417-276-8376
Practice Address - Street 1:811 OWENS MILL RD
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:MO
Practice Address - Zip Code:65785
Practice Address - Country:US
Practice Address - Phone:417-276-5126
Practice Address - Fax:417-276-8376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-19
Last Update Date:2011-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO039681314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101496305Medicaid
MO265466Medicare Oscar/Certification