Provider Demographics
NPI:1760899157
Name:CORYELL COUNTY MEMORIAL HOSPITAL AUTHORITY
Entity Type:Organization
Organization Name:CORYELL COUNTY MEMORIAL HOSPITAL AUTHORITY
Other - Org Name:CRESTVIEW HEALTHCARE RESIDENCE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:K
Authorized Official - Last Name:BYROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:254-248-6300
Mailing Address - Street 1:1400 LAKE SHORE DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76708-3718
Mailing Address - Country:US
Mailing Address - Phone:254-753-0291
Mailing Address - Fax:254-753-3343
Practice Address - Street 1:1400 LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76708-3718
Practice Address - Country:US
Practice Address - Phone:254-753-0291
Practice Address - Fax:254-753-3343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-17
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX004025Medicaid
TX004025Medicaid