Provider Demographics
NPI:1598782096
Name:MEMORIAL HOSPITAL, INC.
Entity Type:Organization
Organization Name:MEMORIAL HOSPITAL, INC.
Other - Org Name:PREFERRED HOME HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:BOGGESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-598-5104
Mailing Address - Street 1:PO BOX 415
Mailing Address - Street 2:
Mailing Address - City:CEREDO
Mailing Address - State:WV
Mailing Address - Zip Code:25507-0415
Mailing Address - Country:US
Mailing Address - Phone:304-453-3590
Mailing Address - Fax:304-453-3594
Practice Address - Street 1:705 C STREET
Practice Address - Street 2:
Practice Address - City:CEREDO
Practice Address - State:WV
Practice Address - Zip Code:25507
Practice Address - Country:US
Practice Address - Phone:304-453-3590
Practice Address - Fax:304-453-3594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY150039251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0004862000Medicaid
WV517127Medicare ID - Type Unspecified