MEDICARE: OPTIMUM DIAGNOSTICS

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	291U00000X	Clinical Medical Laboratory

General Provider Information

NPI Number	:	1295487221
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTIMUM DIAGNOSTICS

Provider Business Mailing Address
First Line	:	1814 BISMARK ST STE A
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38109-1744
Country	:	US
Telephone Number	:	901-628-6302
Fax Number	:

Provider Business Practice Location Address
First Line	:	1814 BISMARK ST STE A
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38109-1744
Country	:	US
Telephone Number	:	901-628-6302
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	URSULA NICOLE MARTIN
Credential	:	RN
Telephone Number	:	901-218-3500

Provider Enumeration Date	:	01/20/2022
Last Update Date	:	01/20/2022

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1083619803 — GUINN CONSULTING SERVICES
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Directions to “OPTIMUM DIAGNOSTICS ” Practice Location

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