1114200805 NPI number — GLEN ROSE I ENTERPRISES, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114200805 NPI number — GLEN ROSE I ENTERPRISES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GLEN ROSE I ENTERPRISES, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114200805
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
203 GIBBS BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLEN ROSE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76043-4309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-897-7361
Provider Business Mailing Address Fax Number:
254-897-3970

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
203 GIBBS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLEN ROSE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76043-4309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-897-7361
Provider Business Practice Location Address Fax Number:
254-897-3970
Provider Enumeration Date:
09/20/2011

Additional Information

Authorized Official

Authorized Official Last Name:
BLAKE
Authorized Official First Name:
GARY
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
817-348-8959

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 001019945 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 005306 . This is a "FACILITY ID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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