1124061304 NPI number — LIBERTY COUNTY HOSPITAL DISTRICT NO. 1

Table of content: (NPI 1124061304)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124061304 NPI number — LIBERTY COUNTY HOSPITAL DISTRICT NO. 1

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIBERTY COUNTY HOSPITAL DISTRICT NO. 1
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:
FAIRFIELD NURSING & REHABILITATION CENTER
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:
1124061304
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/09/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4150 INTERNATIONAL PLAZA
Provider Second Line Business Mailing Address:
SUITE 600
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76109-4831
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-348-8959
Provider Business Mailing Address Fax Number:
817-348-0466

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
420 MOODY ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAIRFIELD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75840-3036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-389-1236
Provider Business Practice Location Address Fax Number:
903-389-1241
Provider Enumeration Date:
06/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STRATTON
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
BRUCE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
936-336-7422

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  102704 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 001014428 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 005486 . This is a "VENDOR" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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