NPIMap

Organization Active NPI

Tallulah Opco LLC

Doing business as Legacy Nursing & Rehabilitation of Tallulah

  • Skilled Nursing Facility
  • Tallulah, LA
National Provider Identifier
1265086979
Registry record updated Jul 31, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
Legal business name
TALLULAH OPCO LLC
Doing business as
Legacy Nursing & Rehabilitation of Tallulah
Practice address
32 Crothers Dr
Tallulah, LA 71282-5510
Phone
(318) 574-8111
Fax
(318) 434-6023
NPI assigned
Jul 31, 2019
Last updated
Jul 31, 2019By the provider in NPPES
Organization subpart
Yes
Parent organization
LEGACY NURSING & REHABILITATION OF TALLULAHAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jul 31, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Devin Gum
Title
Managing Member
Phone
(225) 800-4954

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X NU Primary

Addresses

Primary practice location

32 Crothers Dr
Tallulah, LA 71282-5510

Mailing address

8675 Bluebonnet Blvd Ste a
Baton Rouge, LA 70810-2976

Other names 1

  • LEGACY NURSING & REHABILITATION OF TALLULAH Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in LA

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20191018001516 LA Part A Provider - Skilled Nursing Facility 3375874506 Practice locations: Tallulah, LA

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1265086979. Details of each certification follow.

Skilled nursing facility certification: CCN 195443

Legal name
TALLULAH OPCO LLC
Doing business as
LEGACY NURSING & REHABILITATION OF TALLULAH
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF distinct part
Participating since
Oct 1, 1997
Last certification
Feb 26, 2025
Beds
156
Ownership / control type
Limited Liability Corporation
Organization structure
LLCProprietary
Incorporated
Apr 9, 2019 in LA
Enrollment address
32 Crothers Dr
Tallulah, LA 71282-5510
Nursing home name
LEGACY NURSING AND REHABILITATION OF TALLULAH
Affiliated entity
LEGACY NURSING & REHABILITATION

Care Compare: Nursing home

Medicare Care Compare
Listed as
Legacy Nursing and Rehabilitation of TallulahCCN 195443 · All quality measures
Overall star rating
3 of 5
Health inspections
3 of 5
Staffing
2 of 5
Quality measures
3 of 5
Type
Medicare and Medicaid
Ownership
For profit - Limited Liability company
Certified
Oct 1, 1997
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
15690.0 residents per day on average
Chain
Legacy Nursing & Rehabilitation9 facilities in the chain
Penalties (3 years)
1Fines totaling $3,145

Processed by Care Compare on Aug 1, 2026.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
19D0718988Legacy Nursing & Rehabilitation of Tallulah32 Crothers Drive, Tallulah, LA 71282Certificate of waiverAug 31, 2026

National Provider Directory

National Provider Directory
Part of
Tallulah Opco LLC

Ownership & related parties

All disclosed owners & managing parties 10

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Victor D Gum Individual 5% Or Greater Indirect Ownership InterestSole Member of Managing Member May 1, 2019
Mylesh, LLC Organization, Baton Rouge, LA LLC 5% Or Greater Direct Ownership Interest May 1, 2019
Paige P Grady Individual Operational/Managerial ControlAdministrator May 1, 2019
John Gum Individual 5% Or Greater Indirect Ownership InterestSole Member of Jdgum LLC May 1, 2019
Myles Holyfield Individual 5% Or Greater Indirect Ownership InterestSole Member of Mylesh, LLC May 1, 2019
Jdgum, LLC Organization, Baton Rouge, LA LLC 5% Or Greater Direct Ownership Interest May 1, 2019
VDG LLC Organization, Baton Rouge, LA LLC 5% Or Greater Direct Ownership Interest May 1, 2019
Dgprejean, LLC Organization, Baton Rouge, LA LLC 5% Or Greater Direct Ownership Interest May 1, 2019
Legacy Management Group, LLC Organization, Baton Rouge, LA LLC, For-profit Operational/Managerial Control May 1, 2019
Danielle G Prejean Individual 5% Or Greater Indirect Ownership InterestSole Member of Dgprejean, LLC May 1, 2019

Facilities with the same owner 7

Facilities that share an organizational owner with 5% or greater ownership or operational control.

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

Affiliated clinicians 4

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1564531200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1564531200000",
    "number": "1265086979",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8675 BLUEBONNET BLVD STE A",
            "city": "BATON ROUGE",
            "state": "LA",
            "postal_code": "708102976"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "32 CROTHERS DR",
            "city": "TALLULAH",
            "state": "LA",
            "postal_code": "712825510",
            "telephone_number": "318-574-8111",
            "fax_number": "318-434-6023"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TALLULAH OPCO LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "LEGACY NURSING & REHABILITATION OF TALLULAH",
        "enumeration_date": "2019-07-31",
        "last_updated": "2019-07-31",
        "status": "A",
        "authorized_official_last_name": "GUM",
        "authorized_official_first_name": "DEVIN",
        "authorized_official_title_or_position": "MANAGING MEMBER",
        "authorized_official_telephone_number": "225-800-4954"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "LEGACY NURSING & REHABILITATION OF TALLULAH",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Tallulah, LA

Sources for this page

Verify at the official NPI Registry.