MEDICARE: GCMC OF WHARTON COUNTY TEXAS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	273R00000X	Psychiatric Hospital Unit	008330	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1851522924
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GCMC OF WHARTON COUNTY TEXAS, LLC

Provider Business Mailing Address
First Line	:	PO BOX 4869, DEPT 407A
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77210-4869
Country	:	US
Telephone Number	:	979-282-6141
Fax Number	:	979-282-6036

Provider Business Practice Location Address
First Line	:	10141 US 59 RD
Second Line	:
City	:	WHARTON
State	:	TX
Zip	:	77488-7224
Country	:	US
Telephone Number	:	979-282-6141
Fax Number	:	979-282-6036

Authorized Official
Title or Position	:	DIRECTOR OF BUSINESS SERVICES
Name	:	MRS. NANCY S MONTELLO
Credential	:
Telephone Number	:	979-282-6141

Provider Enumeration Date	:	08/06/2009
Last Update Date	:	01/23/2013

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