Provider Demographics
NPI:1326141557
Name:LIBERTY COUNTY HOSPITAL DISTRICT NO 1
Entity Type:Organization
Organization Name:LIBERTY COUNTY HOSPITAL DISTRICT NO 1
Other - Org Name:COLLEGE STREET HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:A
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-843-5038
Mailing Address - Street 1:13415 MEDICAL COMPLEX DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TOMBALL
Mailing Address - State:TX
Mailing Address - Zip Code:77375-3343
Mailing Address - Country:US
Mailing Address - Phone:832-843-5038
Mailing Address - Fax:832-843-5050
Practice Address - Street 1:4150 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77707-3902
Practice Address - Country:US
Practice Address - Phone:409-842-2244
Practice Address - Fax:409-842-3399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2015-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX141498314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001026457Medicaid
TX675695Medicare Oscar/Certification
TX001004443Medicaid