Healthcare Provider Details

I. General information

NPI: 1013037795
Provider Name (Legal Business Name): MEMORIAL HOME SERVICES OF CENTRAL ILLINOIS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 08/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1935 BELT WAY DR
OVERLAND MO
63114-5825
US

IV. Provider business mailing address

644 N 2ND ST
SPRINGFIELD IL
62702-5222
US

V. Phone/Fax

Practice location:
  • Phone: 314-205-8600
  • Fax:
Mailing address:
  • Phone: 217-788-4663
  • Fax: 217-788-5597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number054-014084
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number004857
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number054-014828
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number054-014084
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code3336S0011X
TaxonomySpecialty Pharmacy
License Number004857
License Number StateMO
# 6
Primary TaxonomyY
Taxonomy Code3336H0001X
TaxonomyHome Infusion Therapy Pharmacy
License Number054-014828
License Number StateIL

VIII. Authorized Official

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