Provider Demographics
NPI:1194134361
Name:MEMORIAL HOME SERVICES OF CENTRAL ILLINOIS, INC
Entity type:Organization
Organization Name:MEMORIAL HOME SERVICES OF CENTRAL ILLINOIS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, DME
Authorized Official - Prefix:MS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:VALENTINE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:217-788-4663
Mailing Address - Street 1:306 N WESTGATE AVE STE A
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62650-3713
Mailing Address - Country:US
Mailing Address - Phone:217-788-4663
Mailing Address - Fax:
Practice Address - Street 1:306 N WESTGATE AVE STE A
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:IL
Practice Address - Zip Code:62650-3713
Practice Address - Country:US
Practice Address - Phone:217-788-4663
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL HOME SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-08-12
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL361190216013Medicaid
IL361190216013Medicaid