Healthcare Provider Details

I. General information

NPI: 1942747514
Provider Name (Legal Business Name): DADE CITY, FL OPCO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2017
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number StateFL

VIII. Authorized Official

Name: ISAAC DOLE
Title or Position: MANAGER/PRINCIPAL
Credential:
Phone: 773-645-9246