Provider Demographics
NPI:1114248663
Name:THOMASVILLE I ENTERPRISES, LLC
Entity Type:Organization
Organization Name:THOMASVILLE I ENTERPRISES, LLC
Other - Org Name:PLANTATION MANOR
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:817-348-8841
Mailing Address - Street 1:220 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-6145
Mailing Address - Country:US
Mailing Address - Phone:229-227-0880
Mailing Address - Fax:229-227-1217
Practice Address - Street 1:220 PARK AVE
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6145
Practice Address - Country:US
Practice Address - Phone:229-227-0880
Practice Address - Fax:229-227-1217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-18
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility