Basic Information
| Provider Information | |||||||||
| NPI: | 1528489614 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CITIZENS MEDICAL CENTER COUNTY OF VICTORIA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CUERO NURSING AND REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2701 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | VICTORIA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 779015748 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3615739181 | ||||||||
| FaxNumber: | 3615725126 | ||||||||
| Practice Location | |||||||||
| Address1: | 1310 E BROADWAY ST | ||||||||
| Address2: | |||||||||
| City: | CUERO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 779542133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3612759133 | ||||||||
| FaxNumber: | 3615729136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2013 | ||||||||
| LastUpdateDate: | 01/16/2020 | ||||||||
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| AuthorizedOfficialLastName: | OLSON | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO/ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3615739181 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| 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 | 358989701 | 05 | TX | MEDICAID | 5314 | 05 | TX | MEDICAID |