Provider Demographics
NPI:1326032186
Name:LIBERTY COUNTY HOSPITAL DISTRICT NO. 1
Entity Type:Organization
Organization Name:LIBERTY COUNTY HOSPITAL DISTRICT NO. 1
Other - Org Name:PINE GROVE NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BOARD PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:C
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:STRATTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-336-7400
Mailing Address - Street 1:1500 WATERS RIDGE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75057-6011
Mailing Address - Country:US
Mailing Address - Phone:972-899-4401
Mailing Address - Fax:972-899-4460
Practice Address - Street 1:246 HALEY DR
Practice Address - Street 2:
Practice Address - City:CENTER
Practice Address - State:TX
Practice Address - Zip Code:75935-9798
Practice Address - Country:US
Practice Address - Phone:936-598-6286
Practice Address - Fax:936-598-6464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-08
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX115789314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001003354Medicaid
TX153792001OtherMEDICAID CO B
AZ675230Medicare Oscar/Certification
AZ675230Medicare Oscar/Certification