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General NPI Number Information
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NPI Number | 1053690818
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Entity Type | Organization
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Legal Business Name | JACKSONVILLE I ENTERPRISES LLC
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Dates
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Enumeration Date | 08/11/2011
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Last Update Date | 08/11/2011
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Provider Practice Location Address
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Address Line | 131 ZIMMERMAN DR.
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City | JACKSONVILLE
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State | TX
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Zip | 75766-0131
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Country | US
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Telephone | 903-283-1208
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Fax | 845-770-3308
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Provider Business Mailing Address
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Address Line | 131 ZIMMERMAN DR.
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City | JACKSONVILLE
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State | TX
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Zip | 75766-0131
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Country | US
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Telephone | 903-283-1208
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Fax | 845-770-3308
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | GARY BLAKE
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Credential |
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Telephone | 817-348-8841
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number |
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License Number State |
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