Healthcare Provider Details

I. General information

NPI: 1265125041
Provider Name (Legal Business Name): SAN ANGELO I ENTERPRISES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2023
Last Update Date: 05/30/2023
Certification Date: 05/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2210 HOWARD ST
SAN ANGELO TX
76901-1318
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 325-944-0561
  • Fax: 325-944-0562
Mailing address:
  • Phone: 817-348-8959
  • 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 BLAKE
Title or Position: MANAGING MEMBER
Credential:
Phone: 817-348-8959