Healthcare Provider Details

I. General information

NPI: 1568612299
Provider Name (Legal Business Name): GROVETON I ENTERPRISES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2008
Last Update Date: 09/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 W 1ST STREET
GROVETON TX
75845
US

IV. Provider business mailing address

PO BOX 890
GROVETON TX
75845-0890
US

V. Phone/Fax

Practice location:
  • Phone: 936-642-1221
  • Fax: 936-642-2727
Mailing address:
  • Phone: 936-642-1221
  • Fax: 936-642-2727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

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