Healthcare Provider Details

I. General information

NPI: 1083883656
Provider Name (Legal Business Name): OPTIMUM HEALTH OF SUWANEE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2008
Last Update Date: 02/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 LAWRENCEVILLE SUWANEE RD
SUWANEE GA
30024-2954
US

IV. Provider business mailing address

2855 HIGHWAY 317 STE 760-318
SUWANEE GA
30024-3563
US

V. Phone/Fax

Practice location:
  • Phone: 678-546-0550
  • Fax: 678-546-6885
Mailing address:
  • Phone: 678-546-0550
  • Fax: 678-730-4378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN P LANIER
Title or Position: OWNER
Credential: MD
Phone: 678-546-0550