Provider Demographics
NPI:1427741206
Name:SAN ANGELO II ENTERPRISES, LLC
Entity type:Organization
Organization Name:SAN ANGELO II ENTERPRISES, LLC
Other - Org Name:
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:817-348-8959
Mailing Address - Street 1:4150 INTERNATIONAL PLZ STE 600
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4831
Mailing Address - Country:US
Mailing Address - Phone:817-348-8959
Mailing Address - Fax:
Practice Address - Street 1:1915 GREENWOOD ST
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76901-1112
Practice Address - Country:US
Practice Address - Phone:325-942-0677
Practice Address - Fax:325-942-1331
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-30
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility