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General NPI Number Information
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NPI Number | 1649156696
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Entity Type | Organization
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Legal Business Name | 1639 OPCO, LLC
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Dates
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Enumeration Date | 08/14/2025
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Last Update Date | 08/14/2025
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Provider Practice Location Address
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Address Line | 1639 NE 26TH ST
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City | WILTON MANORS
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State | FL
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Zip | 33305-1410
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Country | US
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Telephone | 847-917-8337
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Fax |
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Provider Business Mailing Address
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Address Line | 1639 NE 26TH ST
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City | WILTON MANORS
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State | FL
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Zip | 33305-1410
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Country | US
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Telephone | 847-917-8337
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. ROBERT CHARLES VAN FOSSAN
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Credential |
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Telephone | 847-917-8337
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number |
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License Number State |
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