Healthcare Provider Details

I. General information

NPI: 1124268131
Provider Name (Legal Business Name): OPTIMUM CARE CENTERS, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2009
Last Update Date: 07/14/2021
Certification Date: 07/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

418 E 30TH ST
INDIANAPOLIS IN
46205-3909
US

IV. Provider business mailing address

3421 LEE RD
SNELLVILLE GA
30039-5621
US

V. Phone/Fax

Practice location:
  • Phone: 317-641-2026
  • Fax:
Mailing address:
  • Phone: 317-641-2026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number08002356A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code174200000X
TaxonomyMeals Provider
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code261QR1100X
TaxonomyResearch Clinic/Center
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State
# 13
Primary TaxonomyN
Taxonomy Code335G00000X
TaxonomyMedical Foods Supplier
License Number
License Number State
# 14
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. CHUKWUEMEKA KELECHI CHIDEBELU-EZE
Title or Position: C.E.O.
Credential: D.C.
Phone: 317-641-2026