Basic Information
| Provider Information | |||||||||
| NPI: | 1326436189 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEMORIAL MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | ASHFORD GARDENS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 815 N VIRGINIA ST | ||||||||
| Address2: | |||||||||
| City: | PORT LAVACA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 779793025 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 7210 NORTHLINE DR | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770761517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136992882 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2015 | ||||||||
| LastUpdateDate: | 08/26/2015 | ||||||||
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| AuthorizedOfficialLastName: | ANGLIN | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 3615526713 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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 | 67-5423 | 01 | TX | MEDICARE CCN | OTHER |