Healthcare Provider Details

I. General information

NPI: 1104203181
Provider Name (Legal Business Name): MEMORIAL MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2015
Last Update Date: 05/22/2015
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: 361-552-6713
  • Fax: 361-552-0220
Mailing address:
  • Phone: 361-552-6713
  • Fax: 361-552-0220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JASON ANGLIN
Title or Position: CEO
Credential:
Phone: 361-552-6713