1396199477 NPI number — OPTIMALIVING THERAPY LLC

Table of content: (NPI 1396199477)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396199477 NPI number — OPTIMALIVING THERAPY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTIMALIVING THERAPY 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:
OPTIMALIVING THERAPY & WELLNESS CENTER
Provider Other Organization Name Type Code:
3
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:
1396199477
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/14/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13057 W WHISPER ROCK TRL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85383-7952
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-777-3113
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8953 W CUSTER LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85381-3516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-777-3113
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/14/2016

Additional Information

Authorized Official

Authorized Official Last Name:
LEE
Authorized Official First Name:
MELISSA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/OT
Authorized Official Telephone Number:
623-777-3113

Provider Taxonomy Codes

  • Taxonomy code: 2251X0800X , with the licence number:  3809PT , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225XP0019X , with the licence number: 4223 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225XP0019X , with the licence number: 1502 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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