NPIMap

Organization Active NPI

Citizens Memorial Health Care Foundation

Doing business as Citizens Memorial Hospice

  • Community Based Hospice Care Agency
  • Bolivar, MO
National Provider Identifier
1124157169
Registry record updated Feb 18, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Community Based Hospice Care AgencyTaxonomy code 251G00000X
License
003-10H0 Issued in MO
Legal business name
CITIZENS MEMORIAL HEALTH CARE FOUNDATION
Doing business as
Citizens Memorial Hospice
Practice address
111 W Broadway St
Bolivar, MO 65613-1501
Phone
(417) 328-6350
Fax
(417) 328-6987
NPI assigned
Mar 5, 2007
Last updated
Feb 18, 2020By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 18, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Gary D. Fulbright
Title
Executive Director
Phone
(417) 328-6501

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Community Based Hospice Care Agency 251G00000X 003-10H0 MO Primary

Addresses

Primary practice location

111 W Broadway St
Bolivar, MO 65613-1501

Mailing address

1500 N Oakland Ave
Bolivar, MO 65613-3099
Phone (417) 326-6000

Other names 1

  • Citizens Memorial Hospice Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MO

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20180913001197 MO Part A Provider - Hospice 1658413455 Practice locations: Bolivar, MO

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1124157169. Details of each certification follow.

Hospice certification: CCN 261508

Legal name
CITIZENS MEMORIAL HEALTH CARE FOUNDATION
Doing business as
CITIZENS MEMORIAL HOSPICE
Certification status
Active
Provider type (POS)
Hospice
Participating since
Oct 19, 2009
Last certification
Nov 19, 2020
Ownership / control type
Non-Profit - Other
Organization structure
CorporationNon-profit
Incorporated
Sep 24, 1986 in MO
Enrollment address
111 W Broadway St
Bolivar, MO 65613-1501

Other NPIs with the same Medicare PAC ID 10

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Care Compare: Hospice

Medicare Care Compare
Listed as
Citizens Memorial HospiceCCN 261508 · All quality measures
Ownership
Other
Certified
Oct 19, 2009
Medicare certification status
ActiveFrom the Provider of Services file

National Provider Directory

National Provider Directory
Tax ID family
CMH Home Medical Equip14 organizations share this tax ID, including this one

Other organizations with this tax ID 13

Organizations that report the same tax identification number in the National Provider Directory.

View all 13

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 12

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Michael Calhoun Individual Corporate OfficerExecutive Director Jan 1, 2022
W-2 Managing EmployeeCeo Jan 1, 2022
Gary D Fulbright Individual Corporate Director Jan 1, 2024
John Kallenbach Individual Corporate OfficerVice President Jan 1, 2022
Corporate DirectorBoard Member Jun 20, 2019
Kenneth R Smith Individual Corporate Director Jan 1, 2024
Janieca Lynn Hancock Individual Corporate OfficerPresident Jan 1, 2022
Corporate Director Mar 15, 2018
James Ashworth Individual Corporate DirectorBoard Member Jun 17, 2021
Jeffrey R Tedrow Individual W-2 Managing EmployeeMD; Jun 1, 2024
Renee M Meyer Individual Corporate OfficerTreasurer Jan 1, 2022
W-2 Managing EmployeeChief Financial Officer Feb 1, 2020
Katrina S Banner Individual Corporate Director Jan 1, 2024
Valerie R Noblitt Individual W-2 Managing EmployeeAd; May 31, 2024
Donald J Babb Individual Corporate DirectorBoard Member Dec 19, 2019
Dana M Meents Individual Corporate DirectorBoard Member Oct 14, 2010

Owners & managing parties with NPI records 3

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Affiliated clinicians 18

Clinicians who list this facility as an affiliation in Medicare Care Compare.

View all 18

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1173052800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1581984000000",
    "number": "1124157169",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1500 N OAKLAND AVE",
            "city": "BOLIVAR",
            "state": "MO",
            "postal_code": "656133099",
            "telephone_number": "417-326-6000",
            "fax_number": "417-328-6237"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "111 W BROADWAY ST",
            "city": "BOLIVAR",
            "state": "MO",
            "postal_code": "656131501",
            "telephone_number": "417-328-6350",
            "fax_number": "417-328-6987"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CITIZENS MEMORIAL HEALTH CARE FOUNDATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-05",
        "last_updated": "2020-02-18",
        "certification_date": "2020-02-18",
        "status": "A",
        "authorized_official_last_name": "FULBRIGHT",
        "authorized_official_first_name": "GARY",
        "authorized_official_middle_name": "D.",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "417-328-6501"
    },
    "taxonomies": [
        {
            "code": "251G00000X",
            "taxonomy_group": "",
            "desc": "Hospice Care, Community Based",
            "state": "MO",
            "license": "003-10H0",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Citizens Memorial Hospice",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Citizens Memorial Hospice",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Bolivar, MO

Sources for this page

Verify at the official NPI Registry.