Provider Demographics
NPI:1942332671
Name:GRANBURY II ENTERPRISES, LLC
Entity Type:Organization
Organization Name:GRANBURY II ENTERPRISES, LLC
Other - Org Name:THE OAKS OF GRANBURY
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:817-832-3654
Mailing Address - Street 1:1017 LIPAN DR
Mailing Address - Street 2:
Mailing Address - City:GRANBURY
Mailing Address - State:TX
Mailing Address - Zip Code:76048-1560
Mailing Address - Country:US
Mailing Address - Phone:817-279-8885
Mailing Address - Fax:817-569-1908
Practice Address - Street 1:1017 LIPAN DR
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76048-1560
Practice Address - Country:US
Practice Address - Phone:817-279-8885
Practice Address - Fax:817-569-1908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX000569310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX000569Medicaid