Basic Information
| Provider Information | |||||||||
| NPI: | 1750529913 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CALDWELL I ENTERPRISES, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | COPPERAS HOLLOW ASSISTED LIVING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 343 COUNTRY CLUB DR | ||||||||
| Address2: | |||||||||
| City: | CALDWELL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9795676400 | ||||||||
| FaxNumber: | 9795676434 | ||||||||
| Practice Location | |||||||||
| Address1: | 343 COUNTRY CLUB DR | ||||||||
| Address2: | |||||||||
| City: | CALDWELL | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9795676400 | ||||||||
| FaxNumber: | 9795676434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2009 | ||||||||
| LastUpdateDate: | 03/31/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BLAKE | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 8173488841 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.