MEDICARE: OPCO NEW LONDON, MN, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1356997563
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPCO NEW LONDON, MN, LLC

Provider Business Mailing Address
First Line	:	2045 W GRAND AVE STE B34572
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60612-1576
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 GLENOAKS DR
Second Line	:
City	:	NEW LONDON
State	:	MN
Zip	:	56273-9580
Country	:	US
Telephone Number	:	320-354-2231
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	ISAAC DOLE
Credential	:
Telephone Number	:	773-645-9246

Provider Enumeration Date	:	08/13/2019
Last Update Date	:	10/29/2024

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