Basic Information
Provider Information
NPI: 1669551545
EntityType: 2
ReplacementNPI:  
OrganizationName: COMMUNITY MEMORIAL HOSPITAL
LastName:  
FirstName:  
MiddleName:  
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NameSuffix:  
Credential:  
OtherOrganizationName:  
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Mailing Information
Address1: PO BOX 90
Address2:  
City: SOUTH HILL
State: VA
PostalCode: 239700090
CountryCode: US
TelephoneNumber: 4344473151
FaxNumber:  
Practice Location
Address1: 1755 N MECKLENBURG AVENUE
Address2:  
City: SOUTH HILL
State: VA
PostalCode: 239701431
CountryCode: US
TelephoneNumber: 4344473151
FaxNumber:  
Other Information
ProviderEnumerationDate: 11/03/2006
LastUpdateDate: 08/31/2022
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: ALLEN
AuthorizedOfficialFirstName: ELIZABETH
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition: VICE PRESIDENT
AuthorizedOfficialTelephone: 8046281338
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 08/31/2022

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
251E00000X  Y AgenciesHome Health 

ID Information
IDTypeStateIssuerDescription
00497029205VA MEDICAID
00633901 ANTHEMOTHER


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