Provider Demographics
NPI:1114196771
Name:NACOGDOCHES CSNHC ENTERPRISES, LLC
Entity Type:Organization
Organization Name:NACOGDOCHES CSNHC ENTERPRISES, LLC
Other - Org Name:WILLOWBROOK NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-348-8959
Mailing Address - Street 1:227 RUSSELL BLVD
Mailing Address - Street 2:
Mailing Address - City:NACOGDOCHES
Mailing Address - State:TX
Mailing Address - Zip Code:75965-1238
Mailing Address - Country:US
Mailing Address - Phone:936-564-4596
Mailing Address - Fax:936-564-6824
Practice Address - Street 1:227 RUSSELL BLVD
Practice Address - Street 2:
Practice Address - City:NACOGDOCHES
Practice Address - State:TX
Practice Address - Zip Code:75965-1238
Practice Address - Country:US
Practice Address - Phone:936-564-4596
Practice Address - Fax:936-564-6824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-27
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX005225OtherVENDOR STATE
TX001015998Medicaid
TX455700Medicare Oscar/Certification