Healthcare Provider Details

I. General information

NPI: 1912026022
Provider Name (Legal Business Name): OPTIMA CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 SW CEDAR HILLS BLVD SUITE 203
BEAVERTON OR
97005-2027
US

IV. Provider business mailing address

3800 SW CEDAR HILLS BLVD SUITE 203
BEAVERTON OR
97005-2027
US

V. Phone/Fax

Practice location:
  • Phone: 503-526-0734
  • Fax: 503-715-3182
Mailing address:
  • Phone: 503-526-0734
  • Fax: 503-715-3182

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number11769
License Number StateOR

VIII. Authorized Official

Name: STACEY HANKINS
Title or Position: REGISTERED AGENT
Credential: LMT
Phone: 503-526-0734