Provider Demographics
NPI:1235460148
Name:STEPHENVILLE I ENTERPRISES, LLC
Entity Type:Organization
Organization Name:STEPHENVILLE I ENTERPRISES, LLC
Other - Org Name:STEPHENVILLE NURSING AND REHABILITATION
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 1:2311 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:STEPHENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76401-3805
Mailing Address - Country:US
Mailing Address - Phone:254-968-3313
Mailing Address - Fax:254-968-6890
Practice Address - Street 1:2311 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:STEPHENVILLE
Practice Address - State:TX
Practice Address - Zip Code:76401-3805
Practice Address - Country:US
Practice Address - Phone:254-968-3313
Practice Address - Fax:254-968-6890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-18
Last Update Date:2010-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX004051OtherFACILITY ID