Healthcare Provider Details

I. General information

NPI: 1316415532
Provider Name (Legal Business Name): KERENS I ENTERPRISES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2018
Last Update Date: 11/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 NE 4TH ST
KERENS TX
75144-2715
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 903-396-3211
  • Fax: 903-396-2419
Mailing address:
  • Phone:
  • Fax:

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 ROBERT BLAKE
Title or Position: MANAGING MEMBER
Credential:
Phone: 817-348-8959