Basic Information
Provider Information | |||||||||
NPI: | 1780612754 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NACOGDOCHES COUNTY HOSPITAL DISTRICT | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MEMORIAL HOSPITAL CECIL R BOMAR REHAB FACILITY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1204 N MOUND ST | ||||||||
Address2: |   | ||||||||
City: | NACOGDOCHES | ||||||||
State: | TX | ||||||||
PostalCode: | 759614027 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9365644611 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1204 N MOUND ST | ||||||||
Address2: |   | ||||||||
City: | NACOGDOCHES | ||||||||
State: | TX | ||||||||
PostalCode: | 759614027 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9365644611 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/29/2006 | ||||||||
LastUpdateDate: | 07/29/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCCABE | ||||||||
AuthorizedOfficialFirstName: | RHONDA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
AuthorizedOfficialTelephone: | 9365688525 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MEMORIAL HOSPITAL | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | CPA | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283X00000X | 000478 | TX | Y |   | Hospitals | Rehabilitation Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 021798601 | 05 | TX |   | MEDICAID |