Provider Demographics
NPI:1881915338
Name:MOULTRIE I ENTERPRISES, LLC
Entity type:Organization
Organization Name:MOULTRIE I ENTERPRISES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
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 1:3000 VETERANS PKWY S
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31788-7762
Mailing Address - Country:US
Mailing Address - Phone:229-890-3342
Mailing Address - Fax:229-891-3355
Practice Address - Street 1:3000 VETERANS PKWY S
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31788-7762
Practice Address - Country:US
Practice Address - Phone:229-890-3342
Practice Address - Fax:229-891-3355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-18
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility