Healthcare Provider Details

I. General information

NPI: 1396199477
Provider Name (Legal Business Name): OPTIMALIVING THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2016
Last Update Date: 04/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8953 W CUSTER LN
PEORIA AZ
85381-3516
US

IV. Provider business mailing address

13057 W WHISPER ROCK TRL
PEORIA AZ
85383-7952
US

V. Phone/Fax

Practice location:
  • Phone: 623-777-3113
  • Fax:
Mailing address:
  • Phone: 623-777-3113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number3809PT
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number1502
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number4223
License Number StateAZ

VIII. Authorized Official

Name: MRS. MELISSA LEE
Title or Position: OWNER/OT
Credential: OTR/L
Phone: 623-777-3113