1891233276 NPI number — OPTIMUM HEALTHCARE ASSOCIATES, PA

Table of content: (NPI 1891233276)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891233276 NPI number — OPTIMUM HEALTHCARE ASSOCIATES, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTIMUM HEALTHCARE ASSOCIATES, PA
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:
1891233276
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/22/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1906
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39130-1906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-942-8447
Provider Business Mailing Address Fax Number:
949-607-3442

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5350 EXECUTIVE PL
Provider Second Line Business Practice Location Address:
SUITE 8
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39206-4100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-927-1872
Provider Business Practice Location Address Fax Number:
949-607-3442
Provider Enumeration Date:
02/06/2017

Additional Information

Authorized Official

Authorized Official Last Name:
WILSON-SIMPSON
Authorized Official First Name:
FELISA
Authorized Official Middle Name:
DENISE
Authorized Official Title or Position:
OWNER/CEO/NP
Authorized Official Telephone Number:
601-397-6236

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  R784445 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LP0200X , with the licence number: R784445 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





Copyright © 2007-2025 www.npivalidator.com