Basic Information
| Provider Information | |||||||||
| NPI: | 1962495762 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GONZALES HEALTHCARE SYSTEM | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MEMORAL HOSPITAL HOME HEALTH - PHC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 587 | ||||||||
| Address2: | |||||||||
| City: | GONZALES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786290587 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8306727581 | ||||||||
| FaxNumber: | 8306722401 | ||||||||
| Practice Location | |||||||||
| Address1: | 1314 N SARAH DEWITT DR | ||||||||
| Address2: | |||||||||
| City: | GONZALES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786293314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8306729508 | ||||||||
| FaxNumber: | 8306722401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2005 | ||||||||
| LastUpdateDate: | 10/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LACOSTE | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO/ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 8306727581 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 001500 | TX | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 8600 | 05 | TX | MEDICAID |