MEDICARE: OPTALIS BLACKLICK OPCO 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	:	1831036912
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTALIS BLACKLICK OPCO LLC

Provider Business Mailing Address
First Line	:	195 BLOSSOM FIELD BLVD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43213
Country	:	US
Telephone Number	:	614-655-6554
Fax Number	:

Provider Business Practice Location Address
First Line	:	195 BLOSSOM FIELD BLVD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43213
Country	:	US
Telephone Number	:	614-655-6554
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	RAJ PATEL
Credential	:
Telephone Number	:	248-692-4355

Provider Enumeration Date	:	04/29/2026
Last Update Date	:	04/29/2026

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Directions to “OPTALIS BLACKLICK OPCO LLC ” Practice Location

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