Healthcare Provider Details

I. General information

NPI: 1245912724
Provider Name (Legal Business Name): WALLIS ROAD OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2023
Last Update Date: 04/09/2025
Certification Date: 04/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5065 WALLIS RD
WEST PALM BEACH FL
33415-1947
US

IV. Provider business mailing address

5065 WALLIS RD
WEST PALM BEACH FL
33415-1947
US

V. Phone/Fax

Practice location:
  • Phone: 561-689-1799
  • Fax: 561-640-4603
Mailing address:
  • Phone: 561-689-1799
  • Fax: 561-640-4603

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: NATHAN FREUND
Title or Position: MANAGER
Credential:
Phone: 732-730-7480