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General NPI Number Information
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NPI Number | 1457920373
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Entity Type | Organization
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Legal Business Name | DESOTO I ENTERPRISES, LLC
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Dates
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Enumeration Date | 06/24/2021
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Last Update Date | 06/24/2021
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Provider Practice Location Address
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Address Line | 1901 N HAMPTON RD
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City | DESOTO
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State | TX
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Zip | 75115
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Country | US
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Telephone | 817-348-8959
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Fax | 817-348-0466
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Provider Business Mailing Address
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Address Line | 4150 INTERNATIONAL PLZ
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City | FORT WORTH
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State | TX
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Zip | 76109-4892
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Country | US
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Telephone | 817-348-8959
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Fax | 817-348-0466
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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 | 817-348-8959
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number |
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License Number State |
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