Provider Demographics
NPI:1174897730
Name:GREENVILLE I ENTERPRISES LLC
Entity type:Organization
Organization Name:GREENVILLE I ENTERPRISES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
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 1:3500 PARK ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75401-5159
Mailing Address - Country:US
Mailing Address - Phone:903-455-2220
Mailing Address - Fax:903-455-0343
Practice Address - Street 1:3500 PARK ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:TX
Practice Address - Zip Code:75401-5159
Practice Address - Country:US
Practice Address - Phone:903-455-2220
Practice Address - Fax:903-455-0343
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-29
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX004381OtherFACILITY ID
TX001020376Medicaid
TX004381OtherFACILITY ID