MEDICARE: CITIZENS MEMORIAL HEALTH CARE FOUNDATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	039681	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1134109713
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITIZENS MEMORIAL HEALTH CARE FOUNDATION

Provider Business Mailing Address
First Line	:	PO BOX 945
Second Line	:
City	:	STOCKTON
State	:	MO
Zip	:	65785-0945
Country	:	US
Telephone Number	:	417-276-5126
Fax Number	:	417-276-8376

Provider Business Practice Location Address
First Line	:	811 OWENS MILL RD
Second Line	:
City	:	STOCKTON
State	:	MO
Zip	:	65785
Country	:	US
Telephone Number	:	417-276-5126
Fax Number	:	417-276-8376

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. KEVIN COSTELLO
Credential	:
Telephone Number	:	417-276-5126

Provider Enumeration Date	:	01/19/2006
Last Update Date	:	12/11/2011

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