NPIMap

Organization Active NPI

Memorial Medical Center

Doing business as Memorial Medical Clinic

  • Rural Health Clinic/Center
  • Port Lavaca, TX
National Provider Identifier
1497153589
Registry record updated Oct 30, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
MEMORIAL MEDICAL CENTER
Doing business as
Memorial Medical Clinic
Practice address
1016 N Virginia St
Port Lavaca, TX 77979-3000
Phone
(361) 552-0325
Fax
(361) 500-6904
NPI assigned
Dec 5, 2014
Last updated
Oct 30, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 30, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Erin Clevenger
Title
Ceo
Phone
(361) 552-6713

Specialties & licenses 6

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X TX Primary
Family Nurse Practitioner 363LF0000X TX
Family Medicine Physician 207Q00000X TX
Internal Medicine Physician 207R00000X TX
Obstetrics & Gynecology Physician 207V00000X TX
Pediatrics Physician 208000000X

Addresses

Primary practice location

1016 N Virginia St
Port Lavaca, TX 77979-3000

Mailing address

815 N Virginia St
Port Lavaca, TX 77979-3025
Phone (361) 552-6713

Other identifiers 2

IdentifierTypeStateIssuer
673422OtherTXMEDICARE RHC
137909112MedicaidTX

Other names 1

  • MEMORIAL MEDICAL CLINIC Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in TX

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20141022000403 TX Part A Provider - Rural Health Clinic 3072403096 1 other NPI on this enrollment
Practice locations: Port Lavaca, TX

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1497153589. Details of each certification follow.

Rural health clinic certification: CCN 673422

Legal name
MEMORIAL MEDICAL CENTER
Doing business as
MEMORIAL MEDICAL CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Dec 17, 2014
Last certification
May 4, 2021
Ownership / control type
2A
Organization structure
OtherNon-profit
Incorporated
Jul 14, 1947 in TX
Enrollment address
1016 N Virginia St
Memorial Medical Center Clinic
Port Lavaca, TX 77979-3000
Related CCNs
451356

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 5

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
45D2054209Memorial Medical Clinic1016 N Virginia, Port Lavaca, TX 77979Certificate of waiverFeb 14, 2027
45D2099521Memorial Medical Clinic Laboratory1016 N Virginia Street, Port Lavaca, TX 77979ComplianceAug 10, 2026

National Provider Directory

National Provider Directory
Tax ID family
Memorial Med Ctr Amb7 organizations share this tax ID, including this one

Other organizations with this tax ID 6

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 1

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Erin Clevenger Individual Corporate OfficerCeo Apr 1, 2024 100%
W-2 Managing EmployeeAd; Apr 1, 2025 100%
Operational/Managerial ControlCeo Apr 1, 2025 100%

All facility ownership & control disclosures 5

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Memorial Medical CenterPort Lavaca, TX, CCN 451356 Hospital Operational/Managerial Control (100%) Jan 1, 1966
Memorial Medical CenterPort Lavaca, TX, CCN 45Z356 Hospital Operational/Managerial Control (100%) Dec 31, 2021
Golden Creek Healthcare and Rehabilitation CenterNavasota, TX, CCN 676097 Skilled nursing facility 5% Or Greater Direct Ownership Interest (100%) Apr 1, 2017
Lavaca Bay Nursing and Rehabilitation CenterPort Lavaca, TX, CCN 676481 Skilled nursing facility 5% Or Greater Direct Ownership Interest (100%)
Operational/Managerial Control
Adp of the SNF		 Mar 4, 2020
Mar 4, 2020
Feb 27, 2025
Tuscany VillagePearland, TX, CCN 676201 Skilled nursing facility 5% Or Greater Direct Ownership Interest (100%) Mar 1, 2020

Owned or controlled facilities with NPI records 4

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1417737600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1730246400000",
    "number": "1497153589",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "815 N VIRGINIA ST",
            "city": "PORT LAVACA",
            "state": "TX",
            "postal_code": "779793025",
            "telephone_number": "361-552-6713",
            "fax_number": "361-552-0220"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1016 N VIRGINIA ST",
            "city": "PORT LAVACA",
            "state": "TX",
            "postal_code": "779793000",
            "telephone_number": "361-552-0325",
            "fax_number": "361-500-6904"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MEMORIAL MEDICAL CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-12-05",
        "last_updated": "2024-10-30",
        "certification_date": "2024-10-30",
        "status": "A",
        "authorized_official_last_name": "CLEVENGER",
        "authorized_official_first_name": "ERIN",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "361-552-6713"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "TX",
            "license": null,
            "primary": true
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "TX",
            "license": null,
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "TX",
            "license": null,
            "primary": false
        },
        {
            "code": "207R00000X",
            "taxonomy_group": "",
            "desc": "Internal Medicine",
            "state": "TX",
            "license": null,
            "primary": false
        },
        {
            "code": "207V00000X",
            "taxonomy_group": "",
            "desc": "Obstetrics & Gynecology",
            "state": "TX",
            "license": null,
            "primary": false
        },
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE RHC",
            "identifier": "673422",
            "state": "TX"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "137909112",
            "state": "TX"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "MEMORIAL MEDICAL CLINIC",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Port Lavaca, TX

Sources for this page

Verify at the official NPI Registry.