Basic Information
| Provider Information | |||||||||
| NPI: | 1437409562 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | THROCKMORTON I ENTERPRISES, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THROCKMORTON NURSING & REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 N MINTER AVE | ||||||||
| Address2: | |||||||||
| City: | THROCKMORTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764834900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9408492861 | ||||||||
| FaxNumber: | 9408496011 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 N MINTER AVE | ||||||||
| Address2: | |||||||||
| City: | THROCKMORTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 764834900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9408492861 | ||||||||
| FaxNumber: | 9408496011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2012 | ||||||||
| LastUpdateDate: | 09/17/2012 | ||||||||
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| AuthorizedOfficialLastName: | BLAKE | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 8173488841 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 004246 | 01 | TX | FACILITY ID | OTHER |