Provider Demographics
NPI:1568612299
Name:GROVETON I ENTERPRISES, LLC
Entity Type:Organization
Organization Name:GROVETON I ENTERPRISES, LLC
Other - Org Name:GROVETON ASSISTED LIVING
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:PO BOX 890
Mailing Address - Street 2:
Mailing Address - City:GROVETON
Mailing Address - State:TX
Mailing Address - Zip Code:75845-0890
Mailing Address - Country:US
Mailing Address - Phone:936-642-1221
Mailing Address - Fax:936-642-2727
Practice Address - Street 1:1020 W 1ST STREET
Practice Address - Street 2:
Practice Address - City:GROVETON
Practice Address - State:TX
Practice Address - Zip Code:75845
Practice Address - Country:US
Practice Address - Phone:936-642-1221
Practice Address - Fax:936-642-2727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-30
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000502OtherSTATE VENDOR