Provider Demographics
NPI:1518216902
Name:PECOS COUNTY MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:PECOS COUNTY MEMORIAL HOSPITAL
Other - Org Name:SANDERSON RURAL HEATLH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:PENA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:432-336-4880
Mailing Address - Street 1:387 W IH 10
Mailing Address - Street 2:
Mailing Address - City:FORT STOCKTON
Mailing Address - State:TX
Mailing Address - Zip Code:79735-2700
Mailing Address - Country:US
Mailing Address - Phone:432-336-4213
Mailing Address - Fax:432-336-4545
Practice Address - Street 1:213 PERSIMMON STREET
Practice Address - Street 2:
Practice Address - City:SANDERSON
Practice Address - State:TX
Practice Address - Zip Code:79848
Practice Address - Country:US
Practice Address - Phone:432-336-2508
Practice Address - Fax:432-345-2426
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PECOS COUNTY MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-31
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207Q00000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0079AEOtherBCBS GROUP ID