Basic Information
| Provider Information | |||||||||
| NPI: | 1003569492 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEMORIAL HEALTH SYSTEMS INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 707 W GRANADA BLVD | ||||||||
| Address2: | STE 203 | ||||||||
| City: | ORMOND BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321745179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862314252 | ||||||||
| FaxNumber: | 3866762560 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 MEMORIAL MEDICAL PKWY | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321175167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862316000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2022 | ||||||||
| LastUpdateDate: | 01/27/2022 | ||||||||
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| AuthorizedOfficialLastName: | DOMAYER | ||||||||
| AuthorizedOfficialFirstName: | CORY | ||||||||
| AuthorizedOfficialMiddleName: | DOUGLAS | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3862313906 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MEMORIAL HEALTH SYSTEMS INC | ||||||||
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| NPICertificationDate: | 01/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0404X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Cardiac Facilities |
No ID Information.