Provider Demographics
NPI:1003198383
Name:BURNET I ENTERPRISES, LLC
Entity type:Organization
Organization Name:BURNET I ENTERPRISES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
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 1:507 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:BURNET
Mailing Address - State:TX
Mailing Address - Zip Code:78611-3012
Mailing Address - Country:US
Mailing Address - Phone:512-756-6044
Mailing Address - Fax:512-756-2646
Practice Address - Street 1:507 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:BURNET
Practice Address - State:TX
Practice Address - Zip Code:78611-3012
Practice Address - Country:US
Practice Address - Phone:512-756-6044
Practice Address - Fax:512-756-2646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-13
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001019949Medicaid
TX004538OtherFACILITY ID
TX675619Medicare Oscar/Certification