Provider Demographics
NPI:1598869158
Name:MENNONITE MEMORIAL HOME
Entity Type:Organization
Organization Name:MENNONITE MEMORIAL HOME
Other - Org Name:MENNONITE MEMORIAL HOME HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-358-7803
Mailing Address - Street 1:410 W. ELM ST.
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:OH
Mailing Address - Zip Code:45817
Mailing Address - Country:US
Mailing Address - Phone:419-358-7803
Mailing Address - Fax:419-358-4269
Practice Address - Street 1:410 W ELM ST
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:OH
Practice Address - Zip Code:45817-1122
Practice Address - Country:US
Practice Address - Phone:419-358-7803
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MENNONITE MEMORIAL HOME
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-12
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36-7650251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH36-7650Medicare ID - Type Unspecified