Healthcare Provider Details

I. General information

NPI: 1134185523
Provider Name (Legal Business Name): OPTIMUM RESIDENTIAL SERVICES LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2579 WESTERN TRAILS BLVD
AUSTIN TX
78745-1578
US

IV. Provider business mailing address

845 PROTON RD
SAN ANTONIO TX
78258-4203
US

V. Phone/Fax

Practice location:
  • Phone: 210-340-7155
  • Fax:
Mailing address:
  • Phone: 210-340-7155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310500000X
TaxonomyMental Illness Intermediate Care Facility
License Number102416
License Number StateTX

VIII. Authorized Official

Name: MR. MIKE HAWKER
Title or Position: CFO
Credential:
Phone: 210-340-7155