1275814345 NPI number — OPTIMAL PERFORMANCE HEALTH CARE CENTER LLC

Table of content: (NPI 1275814345)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275814345 NPI number — OPTIMAL PERFORMANCE HEALTH CARE CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTIMAL PERFORMANCE HEALTH CARE CENTER 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:
1275814345
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1962 N COMMERCE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53212-3401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-491-8650
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10500 W LOOMIS RD
Provider Second Line Business Practice Location Address:
SUITE 160
Provider Business Practice Location Address City Name:
FRANKLIN
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53132-8030
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-491-8650
Provider Business Practice Location Address Fax Number:
414-810-0894
Provider Enumeration Date:
09/02/2011

Additional Information

Authorized Official

Authorized Official Last Name:
VAN WESTEN
Authorized Official First Name:
COREY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/CLINIC DIRECTOR
Authorized Official Telephone Number:
414-491-8650

Provider Taxonomy Codes

  • Taxonomy code: 111NR0400X , with the licence number:  4410-12 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100002627 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1275814345 . This is a "GROUP NPI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1588628473 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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