Provider Demographics
NPI:1073321022
Name:3900 LLEWELLYN AVENUE OPCO LLC
Entity type:Organization
Organization Name:3900 LLEWELLYN AVENUE OPCO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:HOBACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-698-9040
Mailing Address - Street 1:3900 LLEWELLYN AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23504-1203
Mailing Address - Country:US
Mailing Address - Phone:757-625-5363
Mailing Address - Fax:757-627-3161
Practice Address - Street 1:3900 LLEWELLYN AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23504-1203
Practice Address - Country:US
Practice Address - Phone:757-625-5363
Practice Address - Fax:757-627-3161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-23
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility