Provider Demographics
NPI:1972640506
Name:PALESTINE I ENTERPRISES, LLC
Entity type:Organization
Organization Name:PALESTINE 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:817-348-8959
Mailing Address - Street 1:2404 STATE HIGHWAY 155
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75803-8524
Mailing Address - Country:US
Mailing Address - Phone:903-729-6024
Mailing Address - Fax:903-729-6942
Practice Address - Street 1:2404 STATE HIGHWAY 155
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75803-8524
Practice Address - Country:US
Practice Address - Phone:903-729-6024
Practice Address - Fax:903-729-6942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
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
TX005082Medicaid
TX001014994Medicaid
TX005082Medicaid