Basic Information
| Provider Information | |||||||||
| NPI: | 1912342999 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CORYELL COUNTY MEMORIAL HOSPITAL AUTHORITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HICO NURSING AND REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 617 | ||||||||
| Address2: | |||||||||
| City: | HICO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764570617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2547962111 | ||||||||
| FaxNumber: | 2547962728 | ||||||||
| Practice Location | |||||||||
| Address1: | 712 RAILROAD AVE | ||||||||
| Address2: | |||||||||
| City: | HICO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2547962111 | ||||||||
| FaxNumber: | 2547962728 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2013 | ||||||||
| LastUpdateDate: | 10/13/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BYROM | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | K | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 2542486301 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/13/2022 | ||||||||
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 | 004739 | 01 | TX | FACID | OTHER |