Healthcare Provider Details

I. General information

NPI: 1831036912
Provider Name (Legal Business Name): OPTALIS BLACKLICK OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 BLOSSOM FIELD BLVD
COLUMBUS OH
43213
US

IV. Provider business mailing address

195 BLOSSOM FIELD BLVD
COLUMBUS OH
43213
US

V. Phone/Fax

Practice location:
  • Phone: 614-655-6554
  • Fax:
Mailing address:
  • Phone: 614-655-6554
  • 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: RAJ PATEL
Title or Position: CEO
Credential:
Phone: 248-692-4355