Provider Demographics
NPI:1801896782
Name:MEMORIAL HOME, INC.
Entity type:Organization
Organization Name:MEMORIAL HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:T
Authorized Official - Last Name:STUCKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:620-345-2901
Mailing Address - Street 1:86 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNDRIDGE
Mailing Address - State:KS
Mailing Address - Zip Code:67107-7003
Mailing Address - Country:US
Mailing Address - Phone:620-345-2901
Mailing Address - Fax:620-345-2937
Practice Address - Street 1:86 22ND AVE
Practice Address - Street 2:
Practice Address - City:MOUNDRIDGE
Practice Address - State:KS
Practice Address - Zip Code:67107-7003
Practice Address - Country:US
Practice Address - Phone:620-345-2901
Practice Address - Fax:620-345-2937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-21
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100108790Medicaid
KS175414Medicare ID - Type Unspecified
KS100108790Medicaid