Healthcare Provider Details

I. General information

NPI: 1265086979
Provider Name (Legal Business Name): TALLULAH OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2019
Last Update Date: 07/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 CROTHERS DR
TALLULAH LA
71282-5510
US

IV. Provider business mailing address

8675 BLUEBONNET BLVD STE A
BATON ROUGE LA
70810-2976
US

V. Phone/Fax

Practice location:
  • Phone: 318-574-8111
  • Fax: 318-434-6023
Mailing address:
  • Phone:
  • 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: DEVIN GUM
Title or Position: MANAGING MEMBER
Credential:
Phone: 225-800-4954