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General NPI Number Information
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NPI Number | 1114248663
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Entity Type | Organization
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Legal Business Name | THOMASVILLE I ENTERPRISES, LLC
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Dates
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Enumeration Date | 06/18/2010
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Last Update Date | 06/18/2010
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Provider Practice Location Address
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Address Line | 220 PARK AVE
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City | THOMASVILLE
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State | GA
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Zip | 31792-6145
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Country | US
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Telephone | 229-227-0880
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Fax | 229-227-1217
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Provider Business Mailing Address
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Address Line | 220 PARK AVE
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City | THOMASVILLE
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State | GA
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Zip | 31792-6145
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Country | US
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Telephone | 229-227-0880
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Fax | 229-227-1217
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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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