1740568591 NPI number — OPTIMA SERVICES, PLLC

Table of content: (NPI 1740568591)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740568591 NPI number — OPTIMA SERVICES, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTIMA SERVICES, PLLC
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:
1740568591
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4330 EAST WEST HIGHWAY
Provider Second Line Business Mailing Address:
SUITE 1100
Provider Business Mailing Address City Name:
BETHESDA
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
20814-4408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
301-986-8010
Provider Business Mailing Address Fax Number:
301-986-8011

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11440 COMMERCE PARK DRIVE
Provider Second Line Business Practice Location Address:
LL-4
Provider Business Practice Location Address City Name:
RESTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
20191-1555
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-766-2600
Provider Business Practice Location Address Fax Number:
301-986-8011
Provider Enumeration Date:
07/28/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WALTON
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
R
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
301-986-8010

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: 0101230517 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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