Provider Demographics
NPI:1487992418
Name:BANDERA I ENTERPRISES, LLC
Entity type:Organization
Organization Name:BANDERA 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:817-348-8959
Mailing Address - Street 1:159 MONTAGUE AVE
Mailing Address - Street 2:
Mailing Address - City:BANDERA
Mailing Address - State:TX
Mailing Address - Zip Code:78003-0000
Mailing Address - Country:US
Mailing Address - Phone:830-460-3767
Mailing Address - Fax:830-796-4791
Practice Address - Street 1:159 MONTAGUE AVE
Practice Address - Street 2:
Practice Address - City:BANDERA
Practice Address - State:TX
Practice Address - Zip Code:78003-0000
Practice Address - Country:US
Practice Address - Phone:830-460-3767
Practice Address - Fax:830-796-4791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-25
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX004537OtherDADS FACID
TX001021028Medicaid
675929Medicare Oscar/Certification