Basic Information
| Provider Information | |||||||||
| NPI: | 1760899157 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CORYELL COUNTY MEMORIAL HOSPITAL AUTHORITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CRESTVIEW HEALTHCARE RESIDENCE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 LAKE SHORE DR | ||||||||
| Address2: | |||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767083718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2547530291 | ||||||||
| FaxNumber: | 2547533343 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 LAKE SHORE DR | ||||||||
| Address2: | |||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767083718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2547530291 | ||||||||
| FaxNumber: | 2547533343 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2014 | ||||||||
| LastUpdateDate: | 07/23/2014 | ||||||||
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| AuthorizedOfficialLastName: | BYROM | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2542486300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
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 | 004025 | 05 | TX | MEDICAID |