Basic Information
| Provider Information | |||||||||
| NPI: | 1285272922 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ODESSA II ENTERPRISES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4150 INTERNATIONAL PLZ STE 600 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761094831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4323320371 | ||||||||
| FaxNumber: | 8173480466 | ||||||||
| Practice Location | |||||||||
| Address1: | 1020 N COUNTY RD W | ||||||||
| Address2: | |||||||||
| City: | ODESSA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 797633436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4323320371 | ||||||||
| FaxNumber: | 8173480466 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2019 | ||||||||
| LastUpdateDate: | 12/12/2019 | ||||||||
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| AuthorizedOfficialLastName: | BLAKE | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 8173488959 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/12/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.