Citizens Memorial Health Care Foundation
Organization Active NPI Community Based Hospice Care Agency · Bolivar, MO
NPI 1124157169 · NPPES record last updated Feb 18, 2020
Key facts
- NPI
- 1124157169
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Community Based Hospice Care Agency 251G00000X
- License
- 003-10H0 (MO)
- Legal business name
- CITIZENS MEMORIAL HEALTH CARE FOUNDATION
- Practice address
- 111 W Broadway St
Bolivar, MO 65613-1501 - Phone
- (417) 328-6350
- Fax
- (417) 328-6987
- NPI assigned
- Mar 5, 2007
- Organization subpart
- No
Authorized official
- Name
- Gary D. Fulbright
- Title
- Executive Director
- Phone
- (417) 328-6501
Owners & managing parties with NPI records 3
-
Dana M Meents, M.D.
-
Jeffrey R Tedrow, M.D.
Other NPIs with the same Medicare PAC ID 10
Corporate family (same tax ID) 13
Member of 1
Affiliated clinicians 18
-
Kurt Russell Bravata, M.D.
-
Ronald A Evans, M.D.
-
Louis B Harris, M.D.
-
Mary Lynn Hogan, M.D.
-
Greg Link, DO
-
Kristin Paige Robidou, M.D.
-
Leonid Shunyakov, MD
-
Jeffrey R Tedrow, M.D.
-
Laura C Vance, M.D.
-
Ronald L Vance, M.D.
-
Kendika Abrams, MD
-
Zadesha Gordon, MD
Medicare Care Compare: Hospice
- Listed as
- Citizens Memorial Hospice
- Ownership
- Other
- Certified
- Oct 19, 2009
- Medicare certification status
- Active
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MO
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
- Corporation · Non-profit
- Incorporated
- Sep 24, 1986 in MO
- Enrollment address
- 111 W Broadway St
Bolivar, MO 65613-1501
All disclosed owners & managing parties 12
| Name | Role | Since | Share |
|---|---|---|---|
| Michael Calhoun |
Corporate Officer |
Jan 1, 2022 | |
| W-2 Managing Employee |
Jan 1, 2022 | ||
| Gary D Fulbright |
Corporate Director | Jan 1, 2024 | |
| John Kallenbach |
Corporate Officer |
Jan 1, 2022 | |
| Corporate Director |
Jun 20, 2019 | ||
| Kenneth R Smith |
Corporate Director | Jan 1, 2024 | |
| Janieca Lynn Hancock |
Corporate Officer |
Jan 1, 2022 | |
| Corporate Director | Mar 15, 2018 | ||
| James Ashworth |
Corporate Director |
Jun 17, 2021 | |
| Jeffrey R Tedrow |
W-2 Managing Employee |
Jun 1, 2024 | |
| Renee M Meyer |
Corporate Officer |
Jan 1, 2022 | |
| W-2 Managing Employee |
Feb 1, 2020 | ||
| Katrina S Banner |
Corporate Director | Jan 1, 2024 | |
| Valerie R Noblitt |
W-2 Managing Employee |
May 31, 2024 | |
| Donald J Babb |
Corporate Director |
Dec 19, 2019 | |
| Dana M Meents |
Corporate Director |
Oct 14, 2010 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20180913001197 | MO | Part a Provider - Hospice | 1658413455 | Practice locations: Bolivar, MO |
National Provider Directory
- Tax ID family
- Citizens Memorial Healthcare Foundation Homemaker Plus
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Community Based Hospice Care Agency | 251G00000X | 003-10H0 | MO | Yes |
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
- Citizens Memorial Hospice
Other providers in Bolivar, MO
- Casablanca Care Center, LLC
- Central Care PA
- Central Care, PA
- Chiropractic Health and Wellness Center LLC
- Grace Cidlik
- Citizens Memorial Health Care Foundation
- Citizens Memorial Health Care Foundation
- Citizens Memorial Health Care Foundation
- Citizens Memorial Health Care Foundation
- Citizens Memorial Health Care Foundation
All providers in Bolivar, MO · Community Based Hospice Care Agency in Missouri
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Feb 18, 2020. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.