Healthcare Provider Details

I. General information

NPI: 1730747189
Provider Name (Legal Business Name): OPTIMA PROSTHETICS & ORTHOTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2019
Last Update Date: 01/14/2021
Certification Date: 11/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 SMITHRIDGE DR
RENO NV
89502-5798
US

IV. Provider business mailing address

780 SMITHRIDGE DR
RENO NV
89502-5798
US

V. Phone/Fax

Practice location:
  • Phone: 775-750-7429
  • Fax: 775-499-2707
Mailing address:
  • Phone: 775-229-2503
  • Fax: 775-499-2707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN KIRK WILSON
Title or Position: CEO
Credential: CERTIFIED ORTHOTIST
Phone: 775-750-7429