Provider Demographics
NPI:1265086979
Name:TALLULAH OPCO LLC
Entity type:Organization
Organization Name:TALLULAH OPCO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-800-4954
Mailing Address - Street 1:8675 BLUEBONNET BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70810-2976
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:32 CROTHERS DR
Practice Address - Street 2:
Practice Address - City:TALLULAH
Practice Address - State:LA
Practice Address - Zip Code:71282-5510
Practice Address - Country:US
Practice Address - Phone:318-574-8111
Practice Address - Fax:318-434-6023
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEGACY NURSING & REHABILITATION OF TALLULAH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-07-31
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility