Provider Demographics
NPI:1184073066
Name:MEMORIAL MEDICAL CENTER-SAN AUGUSTINE
Entity type:Organization
Organization Name:MEMORIAL MEDICAL CENTER-SAN AUGUSTINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/CNO
Authorized Official - Prefix:
Authorized Official - First Name:LILLIE
Authorized Official - Middle Name:DARLENE
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-275-3446
Mailing Address - Street 1:200 E LIVINGSTON ST
Mailing Address - Street 2:
Mailing Address - City:SAN AUGUSTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75972-2028
Mailing Address - Country:US
Mailing Address - Phone:936-275-9910
Mailing Address - Fax:936-275-2333
Practice Address - Street 1:200 E LIVINGSTON ST
Practice Address - Street 2:
Practice Address - City:SAN AUGUSTINE
Practice Address - State:TX
Practice Address - Zip Code:75972-2028
Practice Address - Country:US
Practice Address - Phone:936-275-9910
Practice Address - Fax:936-275-2333
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEMORIAL HEALTH SYSTEM OF EAST TEXAS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-06-10
Last Update Date:2016-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000072261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health