Provider Demographics
NPI:1447200118
Name:LIBERTY COUNTY HOSPITAL DISTRICT NO 1
Entity Type:Organization
Organization Name:LIBERTY COUNTY HOSPITAL DISTRICT NO 1
Other - Org Name:AVALON PLACE--KIRBYVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:STRATTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-336-7400
Mailing Address - Street 1:5560 TENNYSON PARKWAY
Mailing Address - Street 2:SUITE 210
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024
Mailing Address - Country:US
Mailing Address - Phone:469-916-6100
Mailing Address - Fax:469-916-6105
Practice Address - Street 1:700 N HERNDON AVE
Practice Address - Street 2:
Practice Address - City:KIRBYVILLE
Practice Address - State:TX
Practice Address - Zip Code:75956-1518
Practice Address - Country:US
Practice Address - Phone:409-423-6111
Practice Address - Fax:409-423-5807
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX105977314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX5201Medicaid
TX5201Medicaid