Provider Demographics
NPI:1780629816
Name:CITRUS MEMORIAL HEALTH FOUNDATION INC
Entity type:Organization
Organization Name:CITRUS MEMORIAL HEALTH FOUNDATION INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFF
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-560-6898
Mailing Address - Street 1:502 W HIGHLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34452-4754
Mailing Address - Country:US
Mailing Address - Phone:352-344-6584
Mailing Address - Fax:
Practice Address - Street 1:502 W HIGHLAND BLVD
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34452-4754
Practice Address - Country:US
Practice Address - Phone:352-344-6584
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CITRUS MEMORIAL HEALTH FOUNDATION INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-20
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL202520951251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010219901Medicaid
FLH86OtherBLUECROSS
FLH86OtherBLUECROSS