Provider Demographics
NPI:1992021661
Name:KILGORE I ENTERPRISES, LLC
Entity Type:Organization
Organization Name:KILGORE I ENTERPRISES, LLC
Other - Org Name:KILGORE HEALTH & 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 1:2700 S HENDERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:KILGORE
Mailing Address - State:TX
Mailing Address - Zip Code:75662-4033
Mailing Address - Country:US
Mailing Address - Phone:903-984-3511
Mailing Address - Fax:903-983-1031
Practice Address - Street 1:2700 S HENDERSON BLVD
Practice Address - Street 2:
Practice Address - City:KILGORE
Practice Address - State:TX
Practice Address - Zip Code:75662-4033
Practice Address - Country:US
Practice Address - Phone:903-984-3511
Practice Address - Fax:903-983-1031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-20
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001018457Medicaid
TX004515OtherFACILITY ID
TX004515OtherFACILITY ID