Healthcare Provider Details

I. General information

NPI: 1740949387
Provider Name (Legal Business Name): OPTIMUS LABS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2021
Last Update Date: 12/13/2021
Certification Date: 12/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

570 MEMORIAL CIR STE 110
ORMOND BEACH FL
32174-5063
US

IV. Provider business mailing address

570 MEMORIAL CIR STE 110
ORMOND BEACH FL
32174-5063
US

V. Phone/Fax

Practice location:
  • Phone: 360-434-0960
  • Fax: 386-287-5776
Mailing address:
  • Phone: 360-434-0960
  • Fax: 386-287-5776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number
License Number State

VIII. Authorized Official

Name: SHANNON RILEY
Title or Position: OWNER
Credential:
Phone: 360-434-0960