Provider Demographics
NPI:1700028289
Name:CALDWELL II ENTERPRISES, LLC
Entity Type:Organization
Organization Name:CALDWELL II ENTERPRISES, LLC
Other - Org Name:COPPERAS HOLLOW NURSING & REHABILITATION 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:817-348-8841
Mailing Address - Street 1:345 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:TX
Mailing Address - Zip Code:77836-2328
Mailing Address - Country:US
Mailing Address - Phone:979-567-4300
Mailing Address - Fax:979-567-4315
Practice Address - Street 1:345 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:TX
Practice Address - Zip Code:77836-2328
Practice Address - Country:US
Practice Address - Phone:979-567-4300
Practice Address - Fax:979-567-4315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-31
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001017065Medicaid