Basic Information
| Provider Information | |||||||||
| NPI: | 1003181777 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CITIZENS MEMORIAL HEALTH CARE FOUNDATION | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 N OAKLAND AVE | ||||||||
| Address2: | |||||||||
| City: | BOLIVAR | ||||||||
| State: | MO | ||||||||
| PostalCode: | 656133011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4173266000 | ||||||||
| FaxNumber: | 4173286242 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 N GRAND ST STE 3 | ||||||||
| Address2: | |||||||||
| City: | GREENFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 656618198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4176370700 | ||||||||
| FaxNumber: | 4173263591 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2012 | ||||||||
| LastUpdateDate: | 03/24/2015 | ||||||||
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| AuthorizedOfficialLastName: | MEYER | ||||||||
| AuthorizedOfficialFirstName: | RENEE | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 4173286258 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 13241672 | MO | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 621752500 | 05 | MO | MEDICAID |