Provider Demographics
NPI:1538337464
Name:OPTIMUM HEALTH OF L'VILLE-GRAYSON
Entity type:Organization
Organization Name:OPTIMUM HEALTH OF L'VILLE-GRAYSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:LANIER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-985-7286
Mailing Address - Street 1:2855 HIGHWAY 317 STE 760-318
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-3563
Mailing Address - Country:US
Mailing Address - Phone:678-546-0550
Mailing Address - Fax:678-546-6885
Practice Address - Street 1:2445 MOON RD
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:GA
Practice Address - Zip Code:30017-7851
Practice Address - Country:US
Practice Address - Phone:678-985-7286
Practice Address - Fax:678-985-7287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2008-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIRO006867111N00000X
GA0288092081S0010X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Multi-Specialty