Healthcare Provider Details

I. General information

NPI: 1639510092
Provider Name (Legal Business Name): MEMORIAL MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2013
Last Update Date: 07/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

815 N VIRGINIA ST
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: 361-552-0325
  • Fax: 361-553-7815
Mailing address:
  • Phone: 361-552-0325
  • Fax: 361-553-7815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. DANETTE BETHANY
Title or Position: DIRECTOR
Credential:
Phone: 361-552-6713