Healthcare Provider Details

I. General information

NPI: 1376352765
Provider Name (Legal Business Name): OPTIMA MED SPA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2024
Last Update Date: 03/09/2025
Certification Date: 03/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 DODGE RD NE SUITE 106 (INSIDE COLDSTREAM HEALTH)
CEDAR RAPIDS IA
52402
US

IV. Provider business mailing address

3315 WILLIAMS BLVD SW # 2-112
CEDAR RAPIDS IA
52404-1478
US

V. Phone/Fax

Practice location:
  • Phone: 319-768-7000
  • Fax:
Mailing address:
  • Phone: 319-573-2891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1201X
TaxonomyObesity and Weight Management Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name: STEPHANIE JOHNSON
Title or Position: OWNER
Credential:
Phone: 319-768-7000