Provider Demographics
NPI:1285605477
Name:CITIZENS MEMORIAL HEALTH CARE FOUNDATION
Entity type:Organization
Organization Name:CITIZENS MEMORIAL HEALTH CARE FOUNDATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:D
Authorized Official - Last Name:FULBRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-328-6501
Mailing Address - Street 1:1500 N OAKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BOLIVAR
Mailing Address - State:MO
Mailing Address - Zip Code:65613-3011
Mailing Address - Country:US
Mailing Address - Phone:417-326-6000
Mailing Address - Fax:417-328-6242
Practice Address - Street 1:1915 S SPRINGFIELD AVE
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:MO
Practice Address - Zip Code:65613-9684
Practice Address - Country:US
Practice Address - Phone:417-326-3584
Practice Address - Fax:417-326-3591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-27
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO13241672332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO621752500Medicaid
MO0288550001Medicare ID - Type UnspecifiedMEDICARE - HME