Healthcare Provider Details

I. General information

NPI: 1871551622
Provider Name (Legal Business Name): WOODVILLE II ENTERPRISES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 08/30/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

647 US HIGHWAY 190 W
WOODVILLE TX
75979-6758
US

IV. Provider business mailing address

647 US HIGHWAY 190 W
WOODVILLE TX
75979-6758
US

V. Phone/Fax

Practice location:
  • Phone: 409-283-8147
  • Fax: 409-283-3919
Mailing address:
  • Phone: 409-283-8147
  • Fax: 409-283-3919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number111622
License Number StateTX

VIII. Authorized Official

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