Provider Demographics
NPI:1124049937
Name:COMMUNITY MEMORIAL HEALTHCARE, INC.
Entity type:Organization
Organization Name:COMMUNITY MEMORIAL HEALTHCARE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:THERESE
Authorized Official - Middle Name:M
Authorized Official - Last Name:LANDOLL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:785-562-2311
Mailing Address - Street 1:808 N 19TH ST
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:66508-1358
Mailing Address - Country:US
Mailing Address - Phone:785-562-2303
Mailing Address - Fax:785-562-2034
Practice Address - Street 1:808 N 19TH ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:KS
Practice Address - Zip Code:66508-1358
Practice Address - Country:US
Practice Address - Phone:785-562-2303
Practice Address - Fax:785-562-2034
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY MEMORIAL HEALTHCARE, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-21
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CD1965OtherRAILROAD MEDICARE
KS110007OtherBLUE CROSS/BLUE SHIELD KS
CD1965OtherRAILROAD MEDICARE
KS110007OtherBLUE CROSS/BLUE SHIELD KS
KS110007Medicare ID - Type UnspecifiedPART B
NE=========11Medicaid