Healthcare Provider Details

I. General information

NPI: 1609689900
Provider Name (Legal Business Name): 100 WEST QUEEN STREET OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2025
Last Update Date: 01/30/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W QUEEN ST
DALLASTOWN PA
17313-2133
US

IV. Provider business mailing address

100 W QUEEN ST
DALLASTOWN PA
17313-2133
US

V. Phone/Fax

Practice location:
  • Phone: 717-246-1671
  • Fax:
Mailing address:
  • Phone: 717-246-1671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: YISSOCHOR KOMIN
Title or Position: MANAGER OF SOLE MEMBER, OPA OPCO PA
Credential:
Phone: 908-510-8029