1851695316 NPI number — PECOS COUNTY MEMORIAL HOSPITAL

Table of content: (NPI 1851695316)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851695316 NPI number — PECOS COUNTY MEMORIAL HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PECOS COUNTY MEMORIAL HOSPITAL
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FAMILY CARE CENTER WALK IN CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1851695316
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/08/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
387 W I H 10
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT STOCKTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
79735-2700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
432-336-4213
Provider Business Mailing Address Fax Number:
432-336-4545

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
511 N MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT STOCKTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
79735-5623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
432-336-4544
Provider Business Practice Location Address Fax Number:
844-315-6548
Provider Enumeration Date:
12/27/2010

Additional Information

Authorized Official

Authorized Official Last Name:
PENA
Authorized Official First Name:
MELISSA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
432-336-4880

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0079AE . This is a "MEDICARE PART B" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 287117001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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