Healthcare Provider Details

I. General information

NPI: 1639444318
Provider Name (Legal Business Name): CITIZENS MEMORIAL HEALTH CARE FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2012
Last Update Date: 02/13/2020
Certification Date: 02/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N MEDICAL DR
ASH GROVE MO
65604-1005
US

IV. Provider business mailing address

1500 N OAKLAND AVE
BOLIVAR MO
65613-3011
US

V. Phone/Fax

Practice location:
  • Phone: 417-751-2506
  • Fax: 417-326-3591
Mailing address:
  • Phone: 417-326-6000
  • Fax: 417-326-3591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number13241672
License Number StateMO

VIII. Authorized Official

Name: MR. GARY D FULBRIGHT
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 417-328-6501