115 South Providence Road Opco LLC

Primary specialty

Skilled Nursing FacilityTaxonomy code 314000000X

Legal business name

115 SOUTH PROVIDENCE ROAD OPCO LLC

Doing business as

Altira at Wallingford

Practice address

115 S Providence Rd
Wallingford, PA 19086-6333

Phone

(610) 565-3232

NPI assigned

Jan 30, 2025

Last updated

Jan 30, 2025By the provider in NPPES

Organization subpart

Yes

Parent organization

OPA OPCO PARENT LLCAs reported in NPPES

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Yissochor Komin

Title

Manager of Sole Member, Opa Opco PA

Phone

(908) 510-8029

Specialties & licenses 1

Addresses

Other names 1

• Altira at Wallingford Doing business as

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1738195200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1738195200000",
    "number": "1083427306",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "115 S PROVIDENCE RD",
            "city": "WALLINGFORD",
            "state": "PA",
            "postal_code": "190866333",
            "telephone_number": "610-565-3232"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "115 S PROVIDENCE RD",
            "city": "WALLINGFORD",
            "state": "PA",
            "postal_code": "190866333",
            "telephone_number": "610-565-3232"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "115 SOUTH PROVIDENCE ROAD OPCO LLC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "OPA OPCO PARENT LLC",
        "enumeration_date": "2025-01-30",
        "last_updated": "2025-01-30",
        "certification_date": "2025-01-30",
        "status": "A",
        "authorized_official_last_name": "KOMIN",
        "authorized_official_first_name": "YISSOCHOR",
        "authorized_official_title_or_position": "MANAGER OF SOLE MEMBER, OPA OPCO PA",
        "authorized_official_telephone_number": "908-510-8029"
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Altira at Wallingford",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• 115 S Providence Road Operations LLC (Wallingford Borough Skilled Nursing and Rehabilitation Center)
• 115 S. Providence Rd. Opco, LLC
• Paul Gregory Alexander, M.D.
• Jessica Baschoff, LSW
• Caillin Boyle
• Bonnie Russ Breit, OTR
• Katherine Brugger, LPC

• Skilled Nursing Facility in Wallingford, PA
• Providers in Wallingford, PA by specialty
• Skilled Nursing Facility in Pennsylvania

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 30, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.