Healthcare Provider Details

I. General information

NPI: 1225298862
Provider Name (Legal Business Name): AMARILLO II ENTERPRISES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2008
Last Update Date: 06/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1931 MEDI PARK DR
AMARILLO TX
79106-2188
US

IV. Provider business mailing address

1701 RIVER RUN SUITE 304
FORT WORTH TX
76107-6579
US

V. Phone/Fax

Practice location:
  • Phone: 817-348-8959
  • Fax: 817-348-0466
Mailing address:
  • Phone: 817-348-8959
  • Fax: 817-348-0466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: GARY BLAKE
Title or Position: MANAGING MEMBER
Credential:
Phone: 817-348-8841