Healthcare Provider Details

I. General information

NPI: 1215404330
Provider Name (Legal Business Name): BRYAN OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2018
Last Update Date: 11/29/2023
Certification Date: 11/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2817 KENT ST
BRYAN TX
77802-5214
US

IV. Provider business mailing address

2431 S ACADIAN THRUWAY STE 100
BATON ROUGE LA
70808-2300
US

V. Phone/Fax

Practice location:
  • Phone: 979-776-7521
  • Fax: 979-774-0161
Mailing address:
  • Phone: 225-800-4954
  • Fax: 225-308-2278

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