Healthcare Provider Details

I. General information

NPI: 1952584757
Provider Name (Legal Business Name): MADISONVILLE II ENTERPRISES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2007
Last Update Date: 04/13/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 E. COLLARD ST.
MADISONVILLE TX
77864-3306
US

IV. Provider business mailing address

4150 INTERNATIONAL PLAZA SUITE 600
FORT WORTH TX
76109-4831
US

V. Phone/Fax

Practice location:
  • Phone: 936-348-2735
  • Fax: 936-348-6401
Mailing address:
  • Phone: 817-348-8959
  • Fax: 817-348-0466

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateTX

VIII. Authorized Official

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