1760005953 NPI number — EASTLAND MEMORIAL HOSPITAL DISTRICT

Table of content: (NPI 1760005953)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760005953 NPI number — EASTLAND MEMORIAL HOSPITAL DISTRICT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTLAND MEMORIAL HOSPITAL DISTRICT
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:
Provider Other Organization Name Type Code:
6
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:
1760005953
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/26/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
WALNUT STREET CLINIC
Provider Second Line Business Mailing Address:
304 S. DAUGHERTY STREET
Provider Business Mailing Address City Name:
EASTLAND
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76448
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-631-5342
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
WALNUT STREET CLINIC
Provider Second Line Business Practice Location Address:
200 WALNUT STREET CLINIC
Provider Business Practice Location Address City Name:
RANGER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76448-7644
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-647-1182
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/21/2020

Additional Information

Authorized Official

Authorized Official Last Name:
WRIGHT
Authorized Official First Name:
LABAN
Authorized Official Middle Name:
JOE
Authorized Official Title or Position:
CEO/ADMINISTRATOR
Authorized Official Telephone Number:
254-631-5342

Provider Taxonomy Codes

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

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

  • Identifier: 45D0487940 . This is a "CLIA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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