Healthcare Provider Details

I. General information

NPI: 1871873398
Provider Name (Legal Business Name): BEAUMONT I ENTERPRISES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2011
Last Update Date: 08/30/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1175 DENTON ST
BEAUMONT TX
77707-3913
US

IV. Provider business mailing address

1175 DENTON ST
BEAUMONT TX
77707-3913
US

V. Phone/Fax

Practice location:
  • Phone: 409-842-3120
  • Fax: 409-842-9013
Mailing address:
  • Phone: 409-842-3120
  • Fax: 409-842-9013

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: MR. GARY BLAKE
Title or Position: MANAGING MEMBER
Credential:
Phone: 817-348-8959