Provider Demographics
NPI:1295324275
Name:OPCO KEOSAUQUA, IA, LLC
Entity type:Organization
Organization Name:OPCO KEOSAUQUA, IA, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
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:773-645-9246
Mailing Address - Street 1:2045 W GRAND AVE STE B-34572
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:773-645-9246
Mailing Address - Fax:
Practice Address - Street 1:819 COUNTRY LANE RD
Practice Address - Street 2:
Practice Address - City:KEOSAUQUA
Practice Address - State:IA
Practice Address - Zip Code:52565-1001
Practice Address - Country:US
Practice Address - Phone:319-293-3761
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-13
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility