Basic Information
| Provider Information | |||||||||
| NPI: | 1922092790 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEMORIAL MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GULF POINTE PLAZA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1780 HUGHES LANDING BLVD STE 500 | ||||||||
| Address2: | |||||||||
| City: | SPRING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773804009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2814195520 | ||||||||
| FaxNumber: | 2814195527 | ||||||||
| Practice Location | |||||||||
| Address1: | 1008 ENTERPRISE BLVD | ||||||||
| Address2: | |||||||||
| City: | ROCKPORT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 783823201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3617295254 | ||||||||
| FaxNumber: | 3617293820 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2005 | ||||||||
| LastUpdateDate: | 06/14/2021 | ||||||||
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| AuthorizedOfficialLastName: | DASPIT | ||||||||
| AuthorizedOfficialFirstName: | LAURENCE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2814195520 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 115451 | TX | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 314000000X | 128934 | TX | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 001003269 | 05 | TX | MEDICAID | 151208901 | 01 | TX | MEDICAID CO B | OTHER | 001030445 | 05 | TX | MEDICAID |