Provider Demographics
NPI:1669860425
Name:MEMORIAL MEDICAL CENTER
Entity Type:Organization
Organization Name:MEMORIAL MEDICAL CENTER
Other - Org Name:THE CRESCENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:ANGLIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-552-6713
Mailing Address - Street 1:815 N VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:PORT LAVACA
Mailing Address - State:TX
Mailing Address - Zip Code:77979-3025
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11353 SUGAR PARK LN
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478-1407
Practice Address - Country:US
Practice Address - Phone:281-276-2050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-02
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX67-6323OtherMEDICARE CCN