Healthcare Provider Details

I. General information

NPI: 1043275969
Provider Name (Legal Business Name): OPTUM INFUSION SERVICES 100, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 09/22/2021
Certification Date: 09/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

931 D CONKLIN STREET
FARMINGDALE NY
11735
US

IV. Provider business mailing address

931 D CONKLIN STREET
FARMINGDALE NY
11735
US

V. Phone/Fax

Practice location:
  • Phone: 800-346-6348
  • Fax: 866-689-3569
Mailing address:
  • Phone: 800-346-6348
  • Fax: 866-689-3569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number9296L0001
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number020477
License Number StateNY

VIII. Authorized Official

Name: DAVID OBERG
Title or Position: VP, COMPLIANCE
Credential:
Phone: 499-988-5893