Provider Demographics
NPI:1245912724
Name:WALLIS ROAD OPCO LLC
Entity type:Organization
Organization Name:WALLIS ROAD OPCO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FREUND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-730-7480
Mailing Address - Street 1:5065 WALLIS RD
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33415-1947
Mailing Address - Country:US
Mailing Address - Phone:561-689-1799
Mailing Address - Fax:561-640-4603
Practice Address - Street 1:5065 WALLIS RD
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33415-1947
Practice Address - Country:US
Practice Address - Phone:561-689-1799
Practice Address - Fax:561-640-4603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-03
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility