Provider Demographics
NPI:1326239054
Name:GULF BEND MH-MR CENTER
Entity Type:Organization
Organization Name:GULF BEND MH-MR CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:POLZIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-582-2314
Mailing Address - Street 1:6502 NURSERY DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904-1178
Mailing Address - Country:US
Mailing Address - Phone:361-575-0611
Mailing Address - Fax:361-578-5500
Practice Address - Street 1:6502 NURSERY DRIVE
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:361-578-5500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX139213336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXOOP668Medicare PIN