Healthcare Provider Details

I. General information

NPI: 1114196771
Provider Name (Legal Business Name): NACOGDOCHES CSNHC ENTERPRISES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2008
Last Update Date: 02/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 RUSSELL BLVD
NACOGDOCHES TX
75965-1238
US

IV. Provider business mailing address

227 RUSSELL BLVD
NACOGDOCHES TX
75965-1238
US

V. Phone/Fax

Practice location:
  • Phone: 936-564-4596
  • Fax: 936-564-6824
Mailing address:
  • Phone: 936-564-4596
  • Fax: 936-564-6824

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