Healthcare Provider Details

I. General information

NPI: 1699369223
Provider Name (Legal Business Name): OPTIMAL HOME HEALTH CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2021
Last Update Date: 02/25/2021
Certification Date: 02/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 MAIN STREET
ANTONITO CO
81120
US

IV. Provider business mailing address

PO BOX 36
CONEJOS CO
81129-0036
US

V. Phone/Fax

Practice location:
  • Phone: 719-580-2083
  • Fax:
Mailing address:
  • Phone: 719-580-2083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: AUDREA CAMILEE GALLEGOS
Title or Position: RN
Credential: RN
Phone: 719-580-2083