Provider Demographics
NPI:1245413046
Name:MEXIA I ENTERPRISES, LLC
Entity Type:Organization
Organization Name:MEXIA I ENTERPRISES, LLC
Other - Org Name:MEXIA NURSING HOME
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 1:501 E SUMPTER ST
Mailing Address - Street 2:
Mailing Address - City:MEXIA
Mailing Address - State:TX
Mailing Address - Zip Code:76667-2354
Mailing Address - Country:US
Mailing Address - Phone:254-562-5542
Mailing Address - Fax:254-562-2206
Practice Address - Street 1:501 E SUMPTER ST
Practice Address - Street 2:
Practice Address - City:MEXIA
Practice Address - State:TX
Practice Address - Zip Code:76667-2354
Practice Address - Country:US
Practice Address - Phone:254-562-5542
Practice Address - Fax:254-562-2206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-14
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
TX001015684Medicaid
004303OtherDADS VENDOR
TX001015684Medicaid