Healthcare Provider Details

I. General information

NPI: 1770143521
Provider Name (Legal Business Name): ODESSA I ENTERPRISES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2019
Last Update Date: 06/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 ENGLEWOOD LN
ODESSA TX
79762-7073
US

IV. Provider business mailing address

3800 ENGLEWOOD LN
ODESSA TX
79762-7073
US

V. Phone/Fax

Practice location:
  • Phone: 432-362-2583
  • Fax: 432-362-8384
Mailing address:
  • Phone: 432-362-2583
  • Fax: 432-362-8384

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