Provider Demographics
NPI:1942446133
Name:AMARILLO VI ENTERPRISES, LLC
Entity Type:Organization
Organization Name:AMARILLO VI ENTERPRISES, LLC
Other - Org Name:GEORGIA MANOR NURSING HOME
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 1:2611 SW 46TH AVE
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79110-1735
Mailing Address - Country:US
Mailing Address - Phone:806-355-6517
Mailing Address - Fax:806-355-4190
Practice Address - Street 1:2611 SW 46TH AVE
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79110-1735
Practice Address - Country:US
Practice Address - Phone:806-355-6517
Practice Address - Fax:806-355-4190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-18
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001014027Medicaid
004604OtherVENDOR
TX001014027Medicaid