Provider Demographics
NPI:1285668541
Name:GULF BEND MRMR CENTER HCS PROGRAM
Entity Type:Organization
Organization Name:GULF BEND MRMR CENTER HCS PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECOTR
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:POLZIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-575-0611
Mailing Address - Street 1:6502 NURSERY DR.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904-4112
Mailing Address - Country:US
Mailing Address - Phone:361-575-0611
Mailing Address - Fax:361-582-2329
Practice Address - Street 1:6502 NURSERY DR
Practice Address - Street 2:SUITE 100
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-1178
Practice Address - Country:US
Practice Address - Phone:361-575-0611
Practice Address - Fax:361-582-2323
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001007430OtherCONTRACT NUMBER