Provider Demographics
NPI:1659830685
Name:ATLANTIS PENN PLACE OPCO LLC
Entity Type:Organization
Organization Name:ATLANTIS PENN PLACE OPCO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-291-7552
Mailing Address - Street 1:5925 DRY CREEK LN NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-1257
Mailing Address - Country:US
Mailing Address - Phone:319-364-2038
Mailing Address - Fax:
Practice Address - Street 1:1 PENNSYLVANIA PL
Practice Address - Street 2:
Practice Address - City:OTTUMWA
Practice Address - State:IA
Practice Address - Zip Code:52501-2171
Practice Address - Country:US
Practice Address - Phone:641-684-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-19
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility