Provider Demographics
NPI:1437409562
Name:THROCKMORTON I ENTERPRISES, LLC
Entity Type:Organization
Organization Name:THROCKMORTON I ENTERPRISES, LLC
Other - Org Name:THROCKMORTON NURSING & REHABILITATION
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
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 1:1000 N MINTER AVE
Mailing Address - Street 2:
Mailing Address - City:THROCKMORTON
Mailing Address - State:TX
Mailing Address - Zip Code:76483-4900
Mailing Address - Country:US
Mailing Address - Phone:940-849-2861
Mailing Address - Fax:940-849-6011
Practice Address - Street 1:1000 N MINTER AVE
Practice Address - Street 2:
Practice Address - City:THROCKMORTON
Practice Address - State:TX
Practice Address - Zip Code:76483-4900
Practice Address - Country:US
Practice Address - Phone:940-849-2861
Practice Address - Fax:940-849-6011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-17
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX004246OtherFACILITY ID