Healthcare Provider Details

I. General information

NPI: 1336385442
Provider Name (Legal Business Name): MEMPHIS I ENTERPRISES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2008
Last Update Date: 08/30/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 N 18TH ST
MEMPHIS TX
79245-2009
US

IV. Provider business mailing address

1415 N 18TH ST
MEMPHIS TX
79245-2009
US

V. Phone/Fax

Practice location:
  • Phone: 806-259-3566
  • Fax: 806-259-5098
Mailing address:
  • Phone: 806-259-3566
  • Fax: 806-259-5098

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