Healthcare Provider Details

I. General information

NPI: 1942810221
Provider Name (Legal Business Name): 4005 BR SNF, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2020
Last Update Date: 10/05/2020
Certification Date: 10/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4005 NORTH BLVD
BATON ROUGE LA
70806-3830
US

IV. Provider business mailing address

10615 JEFFERSON HWY
BATON ROUGE LA
70809-7230
US

V. Phone/Fax

Practice location:
  • Phone: 225-923-7280
  • Fax: 225-387-5939
Mailing address:
  • Phone: 225-368-3181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. PATRICK MITCHELL
Title or Position: MANAGER
Credential:
Phone: 225-368-3181