Provider Demographics
NPI:1760984587
Name:OPCO FARMINGTON, MO, LLC
Entity type:Organization
Organization Name:OPCO FARMINGTON, MO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ISAAC
Authorized Official - Middle Name:
Authorized Official - Last Name:DOLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:736-459-2467
Mailing Address - Street 1:2045 W GRAND AVE STE B34572
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-1576
Mailing Address - Country:US
Mailing Address - Phone:736-459-2467
Mailing Address - Fax:
Practice Address - Street 1:705 GRAND CANYON DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-2161
Practice Address - Country:US
Practice Address - Phone:573-756-8911
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-07
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility