Healthcare Provider Details

I. General information

NPI: 1528147352
Provider Name (Legal Business Name): OPTIMA DERMATOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 01/11/2024
Certification Date: 01/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1027 BOARDMAN CANFIELD RD
BOARDMAN OH
44512-4227
US

IV. Provider business mailing address

987 BOARDMAN CANFIELD RD
BOARDMAN OH
44512-4222
US

V. Phone/Fax

Practice location:
  • Phone: 330-965-8760
  • Fax: 330-965-9325
Mailing address:
  • Phone: 330-965-8760
  • Fax: 330-965-9325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number35074029
License Number StateOH

VIII. Authorized Official

Name: VICKI GRONER
Title or Position: BILLING MANAGER
Credential:
Phone: 330-965-8760