MEDICARE: OPTIMUM HEALTH CLINIC, PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	4301073442	MI

General Provider Information

NPI Number	:	1275773343
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTIMUM HEALTH CLINIC, PC

Provider Business Mailing Address
First Line	:	305 THOMAS ST
Second Line	:	SUITE B
City	:	ALLEGAN
State	:	MI
Zip	:	49010-9158
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	305 THOMAS ST
Second Line	:	SUITE B
City	:	ALLEGAN
State	:	MI
Zip	:	49010-9158
Country	:	US
Telephone Number	:	269-673-2179
Fax Number	:

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	LAURIE L BOURDO
Credential	:
Telephone Number	:	269-673-2179

Provider Enumeration Date	:	03/02/2009
Last Update Date	:	03/02/2009

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