Provider Demographics
NPI:1598910291
Name:JEFFERSON I ENTERPRISES, LLC
Entity Type:Organization
Organization Name:JEFFERSON I ENTERPRISES, LLC
Other - Org Name:PINE HILL 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 1:1307 MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:TX
Mailing Address - Zip Code:75657-1009
Mailing Address - Country:US
Mailing Address - Phone:903-665-9351
Mailing Address - Fax:903-665-7230
Practice Address - Street 1:1307 MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:TX
Practice Address - Zip Code:75657-1009
Practice Address - Country:US
Practice Address - Phone:903-665-9351
Practice Address - Fax:903-665-7230
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-21
Last Update Date:2015-02-25
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
TX005288OtherSTATE VENDOR
TX001016514Medicaid
TX001016514Medicaid