Provider Demographics
NPI:1851465629
Name:COMMUNITY MEMORIAL HEALTHCENTER
Entity Type:Organization
Organization Name:COMMUNITY MEMORIAL HEALTHCENTER
Other - Org Name:COMMUNITY MEMORIAL DIALYSIS
Other - Org Type:Other Name
Authorized Official - Title/Position:VP OF FINANCE, CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:RONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:TATUM
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:434-774-2400
Mailing Address - Street 1:PO BOX 90
Mailing Address - Street 2:
Mailing Address - City:SOUTH HILL
Mailing Address - State:VA
Mailing Address - Zip Code:23970-0090
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 BUENA VISTA CIR
Practice Address - Street 2:
Practice Address - City:SOUTH HILL
Practice Address - State:VA
Practice Address - Zip Code:23970-1431
Practice Address - Country:US
Practice Address - Phone:434-774-2400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004900987Medicaid
VA000055OtherANTHEM