Basic Information
| Provider Information | |||||||||
| NPI: | 1144641234 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CITIZENS MEDICAL CENTER COUNTY OF VICTORIA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PORT LAVACA NURSING AND REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2701 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | VICTORIA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 779015748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3615739181 | ||||||||
| FaxNumber: | 3615725126 | ||||||||
| Practice Location | |||||||||
| Address1: | 524 VILLAGE RD | ||||||||
| Address2: | |||||||||
| City: | PORT LAVACA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 779792380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3615523741 | ||||||||
| FaxNumber: | 3615525808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2013 | ||||||||
| LastUpdateDate: | 01/16/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | OLSON | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO/ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3615739181 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/16/2020 | ||||||||
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 | 4259 | 05 | TX | MEDICAID | 362007201 | 05 | TX | MEDICAID | 001025710 | 05 | TX | MEDICAID |