Provider Demographics
NPI:1619113644
Name:MCLEAN I ENTERPRISES, LLC
Entity Type:Organization
Organization Name:MCLEAN I ENTERPRISES, LLC
Other - Org Name:MCLEAN CARE CENTER
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:817-348-8959
Mailing Address - Street 1:PO BOX 780
Mailing Address - Street 2:
Mailing Address - City:MCLEAN
Mailing Address - State:TX
Mailing Address - Zip Code:79057-0780
Mailing Address - Country:US
Mailing Address - Phone:806-779-2469
Mailing Address - Fax:806-779-2515
Practice Address - Street 1:605 W SEVENTH ST
Practice Address - Street 2:
Practice Address - City:MCLEAN
Practice Address - State:TX
Practice Address - Zip Code:79057-0780
Practice Address - Country:US
Practice Address - Phone:806-779-2469
Practice Address - Fax:806-779-2515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-22
Last Update Date:2021-08-30
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
TX001016678Medicaid
005156OtherVENDOR
005156OtherVENDOR