Provider Demographics
NPI:1376672238
Name:CITIZENS MEMORIAL HEALTH CARE FOUNDATION
Entity Type:Organization
Organization Name:CITIZENS MEMORIAL HEALTH CARE FOUNDATION
Other - Org Name:CITIZENS MEMORIAL HOME HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:FULBRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-328-6501
Mailing Address - Street 1:1500 N OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-3099
Mailing Address - Country:US
Mailing Address - Phone:417-326-6000
Mailing Address - Fax:417-328-6237
Practice Address - Street 1:111 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-1501
Practice Address - Country:US
Practice Address - Phone:417-328-6350
Practice Address - Fax:417-328-6987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2-22251E00000X
251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO267196Medicare Oscar/Certification
26-7196Medicare PIN
MO26-7196Medicare PIN