Healthcare Provider Details

I. General information

NPI: 1699256982
Provider Name (Legal Business Name): EL PASO V ENTERPRISES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2018
Last Update Date: 08/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11608 SCOTT SIMPSON DR
EL PASO TX
79936-6210
US

IV. Provider business mailing address

4150 INTERNATIONAL PLZ STE 600
FORT WORTH TX
76109-4831
US

V. Phone/Fax

Practice location:
  • Phone: 915-857-0071
  • Fax: 915-857-0118
Mailing address:
  • Phone: 915-857-0071
  • Fax: 915-857-0118

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: 817-348-8959