Provider Demographics
NPI:1326690066
Name:LAUREATE BOURBONNAIS OPERATIONS LLC
Entity Type:Organization
Organization Name:LAUREATE BOURBONNAIS OPERATIONS LLC
Other - Org Name:BOURBONNAIS TERRACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:SHAUN
Authorized Official - Middle Name:
Authorized Official - Last Name:AHMAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-426-8849
Mailing Address - Street 1:13024 BALLANTYNE CORPORATE PL STE 425
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-4420
Mailing Address - Country:US
Mailing Address - Phone:704-426-8849
Mailing Address - Fax:
Practice Address - Street 1:133 MOHAWK DR
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-1349
Practice Address - Country:US
Practice Address - Phone:815-937-4790
Practice Address - Fax:815-937-0432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-12
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness