Basic Information
Provider Information | |||||||||
NPI: | 1205807898 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CITIZENS MEMORIAL HEALTH CARE FOUNDATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CITIZENS MEMORIAL HME-BUFFALO | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1500 N OAKLAND AVE | ||||||||
Address2: |   | ||||||||
City: | BOLIVAR | ||||||||
State: | MO | ||||||||
PostalCode: | 656133011 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4173266000 | ||||||||
FaxNumber: | 4173286242 | ||||||||
Practice Location | |||||||||
Address1: | 309 S ASH ST | ||||||||
Address2: | SUITE 101 | ||||||||
City: | BUFFALO | ||||||||
State: | MO | ||||||||
PostalCode: | 656228300 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4173452244 | ||||||||
FaxNumber: | 4173263591 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/31/2006 | ||||||||
LastUpdateDate: | 02/13/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FULBRIGHT | ||||||||
AuthorizedOfficialFirstName: | GARY | ||||||||
AuthorizedOfficialMiddleName: | D | ||||||||
AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 4173286501 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/13/2020 |
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 |