MEDICARE: JACKSONVILLE I ENTERPRISES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility

General Provider Information

NPI Number	:	1053690818
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACKSONVILLE I ENTERPRISES LLC

Provider Business Mailing Address
First Line	:	131 ZIMMERMAN DR.
Second Line	:
City	:	JACKSONVILLE
State	:	TX
Zip	:	75766-0131
Country	:	US
Telephone Number	:	903-283-1208
Fax Number	:	845-770-3308

Provider Business Practice Location Address
First Line	:	131 ZIMMERMAN DR.
Second Line	:
City	:	JACKSONVILLE
State	:	TX
Zip	:	75766-0131
Country	:	US
Telephone Number	:	903-283-1208
Fax Number	:	845-770-3308

Authorized Official
Title or Position	:	MANAGING MEMBER
Name	:	GARY BLAKE
Credential	:
Telephone Number	:	817-348-8841

Provider Enumeration Date	:	08/11/2011
Last Update Date	:	08/11/2011

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