Provider Demographics
NPI:1174625107
Name:CONCHO COUNTY HOSPITAL
Entity type:Organization
Organization Name:CONCHO COUNTY HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTANUELA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:325-869-5911
Mailing Address - Street 1:119 S ELLIS
Mailing Address - Street 2:
Mailing Address - City:MENARD
Mailing Address - State:TX
Mailing Address - Zip Code:76859-0889
Mailing Address - Country:US
Mailing Address - Phone:325-396-4612
Mailing Address - Fax:325-396-2055
Practice Address - Street 1:119 SOUTH ELLIS
Practice Address - Street 2:
Practice Address - City:MENARD
Practice Address - State:TX
Practice Address - Zip Code:76859-0889
Practice Address - Country:US
Practice Address - Phone:325-396-4612
Practice Address - Fax:325-396-2055
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CONCHO COUNTY HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-01
Last Update Date:2009-03-17
Deactivation Date:2007-09-14
Deactivation Code:
Reactivation Date:2007-11-30
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX673839Medicare ID - Type UnspecifiedRURAL HEALTH CLINIC