1851487946 NPI number — OPTIMUM HEALTH MANAGEMENT CORPORATION

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 1851487946 NPI number — OPTIMUM HEALTH MANAGEMENT CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTIMUM HEALTH MANAGEMENT CORPORATION
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:
6
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:
1851487946
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4024 LAWRENCEVILLE HWY NW STE 18
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LILBURN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30047-2805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-924-9901
Provider Business Mailing Address Fax Number:
678-924-9788

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4024 LAWRENCEVILLE HWY NW STE 18
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LILBURN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30047-2805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-924-9901
Provider Business Practice Location Address Fax Number:
678-924-9788
Provider Enumeration Date:
10/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
OZOH
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
LARRY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
678-924-9901

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

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





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