Basic Information
| Provider Information | |||||||||
| NPI: | 1568737161 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| 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: | 1521 S 3RD STREET | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 657859608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172762401 | ||||||||
| FaxNumber: | 4173263591 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2012 | ||||||||
| LastUpdateDate: | 02/14/2020 | ||||||||
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| AuthorizedOfficialLastName: | FULBRIGHT | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4173286501 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 02/14/2020 | ||||||||
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 |