Healthcare Provider Details

I. General information

NPI: 1275180655
Provider Name (Legal Business Name): WINNSBORO OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2019
Last Update Date: 08/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 POLK ST
WINNSBORO LA
71295-2350
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 318-435-6116
  • Fax: 318-435-3993
Mailing address:
  • Phone: 225-800-4954
  • 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: VICTOR DEVIN GUM
Title or Position: MANAGER
Credential:
Phone: 225-800-4954