Provider Demographics
NPI:1053599613
Name:MEMORIAL HOME CARE, INC.
Entity type:Organization
Organization Name:MEMORIAL HOME CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP & GENERAL MGR
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:CONRAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:1574-647-8777
Mailing Address - Street 1:3355 DOUGLAS RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1781
Mailing Address - Country:US
Mailing Address - Phone:574-273-2273
Mailing Address - Fax:
Practice Address - Street 1:3355 DOUGLAS RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1781
Practice Address - Country:US
Practice Address - Phone:574-273-2273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-06
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10-012264-1251E00000X
IN69000137A332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100263690Medicaid
IN100301140AMedicaid
IN100301140AMedicaid