Provider Demographics
NPI:1235528894
Name:CORYELL COUNTY MEMORIAL HOSPITAL AUTHORITY
Entity Type:Organization
Organization Name:CORYELL COUNTY MEMORIAL HOSPITAL AUTHORITY
Other - Org Name:WEST SIDE CAMPUS OF CARE
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 1:1950 S LAS VEGAS TRL
Mailing Address - Street 2:
Mailing Address - City:WHITE SETTLEMENT
Mailing Address - State:TX
Mailing Address - Zip Code:76108-3350
Mailing Address - Country:US
Mailing Address - Phone:817-246-4995
Mailing Address - Fax:817-246-1025
Practice Address - Street 1:1950 S LAS VEGAS TRL
Practice Address - Street 2:
Practice Address - City:WHITE SETTLEMENT
Practice Address - State:TX
Practice Address - Zip Code:76108-3350
Practice Address - Country:US
Practice Address - Phone:817-246-4995
Practice Address - Fax:817-246-1025
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-20
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX005204Medicaid
TX455592Medicare Oscar/Certification