Healthcare Provider Details

I. General information

NPI: 1942332671
Provider Name (Legal Business Name): GRANBURY II ENTERPRISES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 10/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1017 LIPAN DR
GRANBURY TX
76048-1560
US

IV. Provider business mailing address

1017 LIPAN DR
GRANBURY TX
76048-1560
US

V. Phone/Fax

Practice location:
  • Phone: 817-279-8885
  • Fax: 817-569-1908
Mailing address:
  • Phone: 817-279-8885
  • Fax: 817-569-1908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number000569
License Number StateTX

VIII. Authorized Official

Name: GARY BLAKE
Title or Position: MANAGING MEMBER
Credential:
Phone: 817-832-3654