=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942332671
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRANBURY II ENTERPRISES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2007
-----------------------------------------------------
Last Update Date | 10/31/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1017 LIPAN DR
-----------------------------------------------------
City | GRANBURY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76048-1560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-279-8885
-----------------------------------------------------
Fax | 817-569-1908
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1017 LIPAN DR
-----------------------------------------------------
City | GRANBURY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76048-1560
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-279-8885
-----------------------------------------------------
Fax | 817-569-1908
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING MEMBER
-----------------------------------------------------
Name | GARY BLAKE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 817-832-3654
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number | 000569
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------