Provider Demographics
NPI:1730747189
Name:OPTIMA PROSTHETICS & ORTHOTICS, LLC
Entity type:Organization
Organization Name:OPTIMA PROSTHETICS & ORTHOTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:KIRK
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:CERTIFIED ORTHOTIST
Authorized Official - Phone:775-750-7429
Mailing Address - Street 1:780 SMITHRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-5798
Mailing Address - Country:US
Mailing Address - Phone:775-229-2503
Mailing Address - Fax:775-499-2707
Practice Address - Street 1:780 SMITHRIDGE DR
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89502-5798
Practice Address - Country:US
Practice Address - Phone:775-750-7429
Practice Address - Fax:775-499-2707
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-31
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetistGroup - Single Specialty
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVNV20191397735OtherCOMMERCIAL INSURANCE