Provider Demographics
NPI:1205808946
Name:MEMORIAL HOME SERVICES OF CENTRAL ILLINOIS, INC
Entity type:Organization
Organization Name:MEMORIAL HOME SERVICES OF CENTRAL ILLINOIS, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR DURABLE MEDICAL EQUIPMENT
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:VALENTINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-788-4663
Mailing Address - Street 1:644 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-5222
Mailing Address - Country:US
Mailing Address - Phone:217-788-4663
Mailing Address - Fax:217-788-5597
Practice Address - Street 1:1214 WOODLAWN RD UNIT B3
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:IL
Practice Address - Zip Code:62656-9746
Practice Address - Country:US
Practice Address - Phone:217-732-8071
Practice Address - Fax:217-732-8318
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL HOME SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-02-06
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL203000924332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========010Medicaid
IL=========010Medicaid