Provider Demographics
NPI:1437117272
Name:LIBERTY COUNTY HOSPITAL DISTRICT NO. 1
Entity Type:Organization
Organization Name:LIBERTY COUNTY HOSPITAL DISTRICT NO. 1
Other - Org Name:PINE TREE LODGE NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:STRATTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-336-7422
Mailing Address - Street 1:4150 INTERNATIONAL PLAZA
Mailing Address - Street 2:SUITE 600
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4831
Mailing Address - Country:US
Mailing Address - Phone:817-348-8959
Mailing Address - Fax:817-348-0466
Practice Address - Street 1:2711 PINE TREE RD.
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-1646
Practice Address - Country:US
Practice Address - Phone:903-759-3994
Practice Address - Fax:903-759-1439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX111739314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001004827Medicaid
TX004989OtherMEDICAID VENDOR #
TX165860101Medicaid
TX165860101Medicaid