Healthcare Provider Details

I. General information

NPI: 1134109713
Provider Name (Legal Business Name): CITIZENS MEMORIAL HEALTH CARE FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 12/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 OWENS MILL RD
STOCKTON MO
65785
US

IV. Provider business mailing address

PO BOX 945
STOCKTON MO
65785-0945
US

V. Phone/Fax

Practice location:
  • Phone: 417-276-5126
  • Fax: 417-276-8376
Mailing address:
  • Phone: 417-276-5126
  • Fax: 417-276-8376

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number039681
License Number StateMO

VIII. Authorized Official

Name: MR. KEVIN COSTELLO
Title or Position: ADMINISTRATOR
Credential:
Phone: 417-276-5126