Healthcare Provider Details

I. General information

NPI: 1093544033
Provider Name (Legal Business Name): OPCO GRUNDY CENTER, IA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2024
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 E J AVE
GRUNDY CENTER IA
50638-2031
US

IV. Provider business mailing address

2045 W GRAND AVE STE B-34572
CHICAGO IL
60612-1576
US

V. Phone/Fax

Practice location:
  • Phone: 319-824-5436
  • Fax:
Mailing address:
  • Phone: 773-645-9246
  • Fax:

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: ISAAC DOLE
Title or Position: MANAGER OF THE LLC
Credential:
Phone: 773-645-9246