Provider Demographics
NPI:1053690818
Name:JACKSONVILLE I ENTERPRISES LLC
Entity type:Organization
Organization Name:JACKSONVILLE I ENTERPRISES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-348-8841
Mailing Address - Street 1:131 ZIMMERMAN DR.
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75766-0131
Mailing Address - Country:US
Mailing Address - Phone:903-283-1208
Mailing Address - Fax:845-770-3308
Practice Address - Street 1:131 ZIMMERMAN DR.
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766-0131
Practice Address - Country:US
Practice Address - Phone:903-283-1208
Practice Address - Fax:845-770-3308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-11
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility