MEDICARE: 4005 BR SNF, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1942810221
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	4005 BR SNF, LLC

Provider Business Mailing Address
First Line	:	10615 JEFFERSON HWY
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70809-7230
Country	:	US
Telephone Number	:	225-368-3181
Fax Number	:

Provider Business Practice Location Address
First Line	:	4005 NORTH BLVD
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70806-3830
Country	:	US
Telephone Number	:	225-923-7280
Fax Number	:	225-387-5939

Authorized Official
Title or Position	:	MANAGER
Name	:	MR. PATRICK MITCHELL
Credential	:
Telephone Number	:	225-368-3181

Provider Enumeration Date	:	08/03/2020
Last Update Date	:	10/05/2020

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