Provider Demographics
NPI:1437915477
Name:4405 AIRLINE DRIVE OPCO LLC
Entity Type:Organization
Organization Name:4405 AIRLINE DRIVE OPCO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHLOMO
Authorized Official - Middle Name:
Authorized Official - Last Name:MUSHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-251-5131
Mailing Address - Street 1:4405 AIRLINE DR
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-2058
Mailing Address - Country:US
Mailing Address - Phone:318-747-5440
Mailing Address - Fax:318-747-5040
Practice Address - Street 1:4405 AIRLINE DR
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2058
Practice Address - Country:US
Practice Address - Phone:318-747-5440
Practice Address - Fax:318-747-5040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-27
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility