Provider Demographics
NPI:1538249792
Name:MEMORIAL HOSPICE INC
Entity type:Organization
Organization Name:MEMORIAL HOSPICE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:VANELLA
Authorized Official - Middle Name:NOAH
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:662-624-2872
Mailing Address - Street 1:POST OFFICE BOX 1726
Mailing Address - Street 2:600 OHIO STREET
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614
Mailing Address - Country:US
Mailing Address - Phone:662-624-2872
Mailing Address - Fax:662-627-7629
Practice Address - Street 1:600 OHIO STREET
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614
Practice Address - Country:US
Practice Address - Phone:662-624-2872
Practice Address - Fax:662-627-7629
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL HOSPICE INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-16
Last Update Date:2007-08-02
Deactivation Date:2007-07-17
Deactivation Code:
Reactivation Date:2007-08-02
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09586879Medicaid
MS251583Medicare Oscar/Certification