Healthcare Provider Details

I. General information

NPI: 1205808946
Provider Name (Legal Business Name): MEMORIAL HOME SERVICES OF CENTRAL ILLINOIS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 12/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1214 WOODLAWN RD UNIT B3
LINCOLN IL
62656-9746
US

IV. Provider business mailing address

644 N 2ND ST
SPRINGFIELD IL
62702-5222
US

V. Phone/Fax

Practice location:
  • Phone: 217-732-8071
  • Fax: 217-732-8318
Mailing address:
  • Phone: 217-788-4663
  • Fax: 217-788-5597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number203000924
License Number StateIL

VIII. Authorized Official

Name: LORI VALENTINE
Title or Position: DIRECTOR DURABLE MEDICAL EQUIPMENT
Credential:
Phone: 217-788-4663