Provider Demographics
NPI:1801217997
Name:CITIZENS MEDICAL CENTER COUNTY OF VICTORIA
Entity Type:Organization
Organization Name:CITIZENS MEDICAL CENTER COUNTY OF VICTORIA
Other - Org Name:SOUTHBROOKE MANOR NURSING AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-573-9181
Mailing Address - Street 1:2701 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-5748
Mailing Address - Country:US
Mailing Address - Phone:361-573-9181
Mailing Address - Fax:361-572-5126
Practice Address - Street 1:1401 W MAIN ST
Practice Address - Street 2:
Practice Address - City:EDNA
Practice Address - State:TX
Practice Address - Zip Code:77957-2454
Practice Address - Country:US
Practice Address - Phone:361-782-7614
Practice Address - Fax:361-782-5612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-17
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001025756Medicaid
TX361148501Medicaid
TX5302Medicaid