=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427861723
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 1008 THOMPSON STREET OPCO LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2025
-----------------------------------------------------
Last Update Date | 01/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1008 THOMPSON ST
-----------------------------------------------------
City | JERSEY SHORE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17740-1729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-398-4747
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1008 THOMPSON ST
-----------------------------------------------------
City | JERSEY SHORE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17740-1729
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-398-4747
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER OF SOLE MEMBER, OPA OPCO PA
-----------------------------------------------------
Name | YISSOCHOR KOMIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 908-510-8029
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------