Healthcare Provider Details

I. General information

NPI: 1073843504
Provider Name (Legal Business Name): OPTIMUM HEALTH REHAB OF CUMMING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2010
Last Update Date: 01/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

5967 BETHELVIEW RD
CUMMING GA
30040
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number
License Number StateNULL

VIII. Authorized Official

Name: ALEX JUTIS
Title or Position: CEO
Credential: DC
Phone: 678-546-0550