Provider Demographics
NPI:1083162473
Name:MEMORIAL HEALTH SYSTEM OF EAST TEXAS
Entity Type:Organization
Organization Name:MEMORIAL HEALTH SYSTEM OF EAST TEXAS
Other - Org Name:CHI ST LUKE'S HEALTH MEMORIAL IDTF MOBILE UNIT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:SHELLI
Authorized Official - Middle Name:
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-631-6702
Mailing Address - Street 1:PO BOX 1447
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75902-1447
Mailing Address - Country:US
Mailing Address - Phone:936-634-8111
Mailing Address - Fax:
Practice Address - Street 1:1201 W FRANK AVE
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904
Practice Address - Country:US
Practice Address - Phone:936-634-8111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CATHOLIC HEALTH INITIATIVES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-09-14
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM2500X, 261QR0208X
TX00129282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile
No282N00000XHospitalsGeneral Acute Care Hospital