Provider Demographics
NPI:1639384597
Name:CITIZENS MEMORIAL HEALTH CARE FOUNDATION
Entity Type:Organization
Organization Name:CITIZENS MEMORIAL HEALTH CARE FOUNDATION
Other - Org Name:MILES FOR SMILES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:BABB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-326-6501
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:417-326-6334
Mailing Address - Fax:417-328-7727
Practice Address - Street 1:1500 N. OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-3099
Practice Address - Country:US
Practice Address - Phone:417-328-6334
Practice Address - Fax:417-328-7727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO505162107Medicare ID - Type Unspecified