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NPI Code Detail

MEDICARE: ODESSA II ENTERPRISES, LLC

MEDICARE: ODESSA II ENTERPRISES, LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1314000000XSkilled Nursing Facility

General Provider Information

NPI Number : 1285272922
Entity Type Code : Organization
Provider Name (Legal Business Name) : ODESSA II ENTERPRISES, LLC
Provider Business Mailing Address
First Line : 4150 INTERNATIONAL PLZ STE 600
Second Line :
City : FORT WORTH
State : TX
Zip : 76109-4831
Country : US
Telephone Number : 432-332-0371
Fax Number : 817-348-0466
Provider Business Practice Location Address
First Line : 1020 N COUNTY RD W
Second Line :
City : ODESSA
State : TX
Zip : 79763-3436
Country : US
Telephone Number : 432-332-0371
Fax Number : 817-348-0466
Authorized Official
Title or Position : MANAGING MEMBER
Name : GARY BLAKE
Credential :
Telephone Number : 817-348-8959
Provider Enumeration Date : 12/12/2019
Last Update Date : 12/12/2019

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Directions to “ODESSA II ENTERPRISES, LLC ” Practice Location

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