Provider Demographics
NPI:1063588960
Name:CITIZENS MEMORIAL HEALTHCARE
Entity type:Organization
Organization Name:CITIZENS MEMORIAL HEALTHCARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR SPECIALTY CLINIC & PHYSICA
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:VICKERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-328-6908
Mailing Address - Street 1:1240 N BUTTERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-3016
Mailing Address - Country:US
Mailing Address - Phone:417-326-6021
Mailing Address - Fax:417-326-6347
Practice Address - Street 1:1240 N BUTTERFIELD RD
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-3016
Practice Address - Country:US
Practice Address - Phone:417-326-6021
Practice Address - Fax:417-326-6347
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CITIZENS MEMORIAL HOSPITAL DISTRICT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-24
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO596054304Medicaid
MO596054304Medicaid