Provider Demographics
NPI:1548668098
Name:OPTIMUM PEDIATRIC SERVICES LLC
Entity type:Organization
Organization Name:OPTIMUM PEDIATRIC SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MIRTHA
Authorized Official - Middle Name:T
Authorized Official - Last Name:LAFONTANT
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:888-668-7311
Mailing Address - Street 1:2058 RESERVE PKWY
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-7433
Mailing Address - Country:US
Mailing Address - Phone:888-668-7311
Mailing Address - Fax:888-668-7314
Practice Address - Street 1:2058 RESERVE PKWY
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-7433
Practice Address - Country:US
Practice Address - Phone:888-668-7311
Practice Address - Fax:888-668-7314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-16
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
No251E00000XAgenciesHome Health