Healthcare Provider Details

I. General information

NPI: 1649495474
Provider Name (Legal Business Name): OPTIMUM HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 11/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 N WOLF RD
PROSPECT HEIGHTS IL
60070-1749
US

IV. Provider business mailing address

7 N WOLF RD
PROSPECT HEIGHTS IL
60070-1749
US

V. Phone/Fax

Practice location:
  • Phone: 847-297-2225
  • Fax: 247-297-2096
Mailing address:
  • Phone: 847-297-2225
  • Fax: 247-297-2096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number038009253
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070016717
License Number StateIL

VIII. Authorized Official

Name: MS. DOTTI LOSIK
Title or Position: OFFICE MANAGER
Credential:
Phone: 847-297-2225