Provider Demographics
NPI:1972769404
Name:CITIZENS MEMORIAL HEALTHCARE CLINICS
Entity Type:Organization
Organization Name:CITIZENS MEMORIAL HEALTHCARE CLINICS
Other - Org Name:CMH FOOT & ANKLE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER APPLICATION SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:K
Authorized Official - Last Name:SHEPHERD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-328-7705
Mailing Address - Street 1:PO BOX 939
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-0939
Mailing Address - Country:US
Mailing Address - Phone:417-777-6911
Mailing Address - Fax:417-326-6936
Practice Address - Street 1:1630 KILLINGSWORTH AVE
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-2282
Practice Address - Country:US
Practice Address - Phone:417-326-6200
Practice Address - Fax:417-777-7463
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-04
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO313-25332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO626365001Medicaid