Provider Demographics
NPI:1336286111
Name:PALACIOS COMMUNITY MEDICAL CENTER
Entity Type:Organization
Organization Name:PALACIOS COMMUNITY MEDICAL CENTER
Other - Org Name:PALACIOS MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-972-2511
Mailing Address - Street 1:307 GREEN AVE
Mailing Address - Street 2:
Mailing Address - City:PALACIOS
Mailing Address - State:TX
Mailing Address - Zip Code:77465-3213
Mailing Address - Country:US
Mailing Address - Phone:361-972-2000
Mailing Address - Fax:361-972-2009
Practice Address - Street 1:307 GREEN AVE
Practice Address - Street 2:
Practice Address - City:PALACIOS
Practice Address - State:TX
Practice Address - Zip Code:77465-3213
Practice Address - Country:US
Practice Address - Phone:361-972-2000
Practice Address - Fax:361-972-2009
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PALACIOS COMMUNITY MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-31
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX085552003Medicaid
TX085552003Medicaid
TX458820Medicare Oscar/Certification