Provider Demographics
NPI:1871873398
Name:BEAUMONT I ENTERPRISES, LLC
Entity type:Organization
Organization Name:BEAUMONT 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 1:1175 DENTON ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77707-3913
Mailing Address - Country:US
Mailing Address - Phone:409-842-3120
Mailing Address - Fax:409-842-9013
Practice Address - Street 1:1175 DENTON ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77707-3913
Practice Address - Country:US
Practice Address - Phone:409-842-3120
Practice Address - Fax:409-842-9013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-29
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
TX001019897Medicaid
TX004786OtherFACILITY ID
TX675620Medicare Oscar/Certification