Basic Information
| Provider Information | |||||||||
| NPI: | 1578960647 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEMORIAL MEDICAL CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 815 N VIRGINIA ST | ||||||||
| Address2: | |||||||||
| City: | PORT LAVACA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 779793025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3615520224 | ||||||||
| FaxNumber: | 3615520220 | ||||||||
| Practice Location | |||||||||
| Address1: | 815 N VIRGINIA ST | ||||||||
| Address2: | |||||||||
| City: | PORT LAVACA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 779793025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3615520224 | ||||||||
| FaxNumber: | 3615520220 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2014 | ||||||||
| LastUpdateDate: | 12/04/2014 | ||||||||
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| AuthorizedOfficialLastName: | MOORE | ||||||||
| AuthorizedOfficialFirstName: | DIANE | ||||||||
| AuthorizedOfficialMiddleName: | CHRIS | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3615520224 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X | 000487 | TX | Y | Hospitals | General Acute Care Hospital | Critical Access |
ID Information
| ID | Type | State | Issuer | Description | 137909111 | 05 | TX | MEDICAID |