Healthcare Provider Details

I. General information

NPI: 1326690066
Provider Name (Legal Business Name): LAUREATE BOURBONNAIS OPERATIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2019
Last Update Date: 07/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 MOHAWK DR
BOURBONNAIS IL
60914-1349
US

IV. Provider business mailing address

13024 BALLANTYNE CORPORATE PL STE 425
CHARLOTTE NC
28277-4420
US

V. Phone/Fax

Practice location:
  • Phone: 815-937-4790
  • Fax: 815-937-0432
Mailing address:
  • Phone: 704-426-8849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310500000X
TaxonomyMental Illness Intermediate Care Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. SHAUN AHMAD
Title or Position: MANAGER
Credential:
Phone: 704-426-8849