Healthcare Provider Details

I. General information

NPI: 1073321022
Provider Name (Legal Business Name): 3900 LLEWELLYN AVENUE OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2024
Last Update Date: 02/28/2025
Certification Date: 02/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 LLEWELLYN AVE
NORFOLK VA
23504-1203
US

IV. Provider business mailing address

3900 LLEWELLYN AVE
NORFOLK VA
23504-1203
US

V. Phone/Fax

Practice location:
  • Phone: 757-625-5363
  • Fax: 757-627-3161
Mailing address:
  • Phone: 757-625-5363
  • Fax: 757-627-3161

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: TIFFANY HOBACK
Title or Position: MANAGER
Credential:
Phone: 770-698-9040