Basic Information
| Provider Information | |||||||||
| NPI: | 1053700617 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CORYELL COUNTY MEMORIAL HOSPITAL AUTHORITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BRENTWOOD PLACE THREE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3505 S BUCKNER BLVD BLDG 4 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752275451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143811815 | ||||||||
| FaxNumber: | 2143814454 | ||||||||
| Practice Location | |||||||||
| Address1: | 3505 S BUCKNER BLVD BLDG 4 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752275451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143811815 | ||||||||
| FaxNumber: | 2143814454 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2015 | ||||||||
| LastUpdateDate: | 03/16/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BYROM | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2542486300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 004988 | 05 | TX | MEDICAID |