Provider Demographics
NPI:1922260876
Name:LIBERTY COUNTY HOSPITAL DISTRICT NO. 1
Entity Type:Organization
Organization Name:LIBERTY COUNTY HOSPITAL DISTRICT NO. 1
Other - Org Name:JEFFERSON NURSING AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BOARD PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:C. BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:STRATTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-336-7400
Mailing Address - Street 1:101 W GOODWIN AVE
Mailing Address - Street 2:STE 600
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-6502
Mailing Address - Country:US
Mailing Address - Phone:361-576-0694
Mailing Address - Fax:361-576-5484
Practice Address - Street 1:3840 POINTE PKWY
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77706-2000
Practice Address - Country:US
Practice Address - Phone:409-892-6811
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-01
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX313M00000X, 314000000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001026494Medicaid
TX360896001Medicaid
TX5547Medicaid
TX5547Medicaid
TX6413520001Medicare NSC
TX5547Medicaid