Healthcare Provider Details

I. General information

NPI: 1053964742
Provider Name (Legal Business Name): MEMORIAL MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2019
Last Update Date: 09/19/2025
Certification Date: 09/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 N VIRGINIA ST FL 2
PORT LAVACA TX
77979-3025
US

IV. Provider business mailing address

815 N VIRGINIA ST
PORT LAVACA TX
77979-3025
US

V. Phone/Fax

Practice location:
  • Phone: 361-552-0379
  • Fax: 361-500-6904
Mailing address:
  • Phone: 361-552-0325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ERIN CLEVENGER
Title or Position: CEO
Credential:
Phone: 361-552-6713