Provider Demographics
NPI:1427005578
Name:REFUGIO COUNTY MEMORIAL HOSPITAL DISTRICT
Entity Type:Organization
Organization Name:REFUGIO COUNTY MEMORIAL HOSPITAL DISTRICT
Other - Org Name:AUSTWELL-TIVOLI MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:
Authorized Official - Last Name:WASICEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-526-2321
Mailing Address - Street 1:106 W WILSON
Mailing Address - Street 2:
Mailing Address - City:TIVOLI
Mailing Address - State:TX
Mailing Address - Zip Code:77990-5802
Mailing Address - Country:US
Mailing Address - Phone:361-286-0115
Mailing Address - Fax:361-286-0256
Practice Address - Street 1:106 W WILSON
Practice Address - Street 2:
Practice Address - City:TIVOLI
Practice Address - State:TX
Practice Address - Zip Code:77990-5802
Practice Address - Country:US
Practice Address - Phone:361-286-0115
Practice Address - Fax:361-286-0256
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:REFUGIO CO. MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-27
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QC0050X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261QC0050XAmbulatory Health Care FacilitiesClinic/CenterCritical Access Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0636243-01Medicaid
TX063624302Medicaid
TX063624302Medicaid