Healthcare Provider Details

I. General information

NPI: 1538965330
Provider Name (Legal Business Name): 1102 RIVER ROAD OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2025
Last Update Date: 02/27/2025
Certification Date: 02/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 RIVER RD
BOERNE TX
78006-2436
US

IV. Provider business mailing address

1102 RIVER RD
BOERNE TX
78006-2436
US

V. Phone/Fax

Practice location:
  • Phone: 830-249-2799
  • Fax: 830-541-7265
Mailing address:
  • Phone: 830-249-2799
  • Fax: 830-541-7265

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: CEO
Credential:
Phone: 732-719-5098