MEDICARE: DESOTO I 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
1	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1457920373
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DESOTO I ENTERPRISES, LLC

Provider Business Mailing Address
First Line	:	4150 INTERNATIONAL PLZ
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-4892
Country	:	US
Telephone Number	:	817-348-8959
Fax Number	:	817-348-0466

Provider Business Practice Location Address
First Line	:	1901 N HAMPTON RD
Second Line	:
City	:	DESOTO
State	:	TX
Zip	:	75115
Country	:	US
Telephone Number	:	817-348-8959
Fax Number	:	817-348-0466

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	GARY BLAKE
Credential	:
Telephone Number	:	817-348-8959

Provider Enumeration Date	:	06/24/2021
Last Update Date	:	06/24/2021

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