Provider Demographics
NPI:1952596009
Name:WOLFFORTH I ENTERPRISES, LLC
Entity Type:Organization
Organization Name:WOLFFORTH I ENTERPRISES, LLC
Other - Org Name:VILLA RESIDENTIAL CARE OF WOLFFORTH I, II, III
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 1:301 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:WOLFFORTH
Mailing Address - State:TX
Mailing Address - Zip Code:79382
Mailing Address - Country:US
Mailing Address - Phone:806-866-4666
Mailing Address - Fax:806-866-4111
Practice Address - Street 1:301 E 5TH ST
Practice Address - Street 2:
Practice Address - City:WOLFFORTH
Practice Address - State:TX
Practice Address - Zip Code:79382
Practice Address - Country:US
Practice Address - Phone:806-866-4666
Practice Address - Fax:806-866-4111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-12
Last Update Date:2007-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility