1346755386 NPI number — OPTIMAL PERFORMANCE MEDICINE LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346755386 NPI number — OPTIMAL PERFORMANCE MEDICINE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTIMAL PERFORMANCE MEDICINE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1346755386
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/13/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
210 BROOK VALLEY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSWELL
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30075-2356
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-842-9405
Provider Business Mailing Address Fax Number:
678-250-0701

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 STONEBRIDGE PKWY STE 430
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODSTOCK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30189-3769
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-250-0700
Provider Business Practice Location Address Fax Number:
678-250-0701
Provider Enumeration Date:
12/13/2017

Additional Information

Authorized Official

Authorized Official Last Name:
SKARDASIS
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
GEORGE
Authorized Official Title or Position:
PRACTICE OWNER
Authorized Official Telephone Number:
678-250-0700

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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