Basic Information
| Provider Information | |||||||||
| NPI: | 1770972275 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHG HOSPITAL SULPHUR, LLC | ||||||||
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| OtherOrganizationName: | CORNERSTONE SPECIALTY HOSPITALS SULPHUR | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 ROSS AVE | ||||||||
| Address2: | SUITE 5400 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752012708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4696216700 | ||||||||
| FaxNumber: | 4696216678 | ||||||||
| Practice Location | |||||||||
| Address1: | 524 DR MICHAEL DEBAKEY DR | ||||||||
| Address2: | THIRD FLOOR | ||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 70601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3375271102 | ||||||||
| FaxNumber: | 3375271114 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2015 | ||||||||
| LastUpdateDate: | 11/29/2018 | ||||||||
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| AuthorizedOfficialLastName: | SCHULTZ | ||||||||
| AuthorizedOfficialFirstName: | KURT | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4696216700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282E00000X | 2203782333 | LA | Y | Hospitals | Long Term Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 1762296 | 05 | LA | MEDICAID |