Provider Demographics
NPI:1144619701
Name:CORYELL COUNTY MEMORIAL HOSPITAL AUTHORITY
Entity Type:Organization
Organization Name:CORYELL COUNTY MEMORIAL HOSPITAL AUTHORITY
Other - Org Name:BRENTWOOD PLACE TWO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:K
Authorized Official - Last Name:BYROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-248-6300
Mailing Address - Street 1:3505 S BUCKNER BLVD BLDG 3
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75227-5451
Mailing Address - Country:US
Mailing Address - Phone:214-388-0519
Mailing Address - Fax:214-381-3767
Practice Address - Street 1:3505 S BUCKNER BLVD BLDG 3
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75227-5451
Practice Address - Country:US
Practice Address - Phone:214-388-0519
Practice Address - Fax:214-381-3767
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-20
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX005148Medicaid
TX675702Medicare Oscar/Certification