Basic Information
| Provider Information | |||||||||
| NPI: | 1235528894 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CORYELL COUNTY MEMORIAL HOSPITAL AUTHORITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WEST SIDE CAMPUS OF CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1950 S LAS VEGAS TRL | ||||||||
| Address2: | |||||||||
| City: | WHITE SETTLEMENT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761083350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172464995 | ||||||||
| FaxNumber: | 8172461025 | ||||||||
| Practice Location | |||||||||
| Address1: | 1950 S LAS VEGAS TRL | ||||||||
| Address2: | |||||||||
| City: | WHITE SETTLEMENT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761083350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8172464995 | ||||||||
| FaxNumber: | 8172461025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2015 | ||||||||
| LastUpdateDate: | 07/18/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BYROM | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2542486300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.