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General NPI Number Information
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NPI Number | 1063854743
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Entity Type | Organization
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Legal Business Name | OPTIMUM FOOT CARE
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Dates
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Enumeration Date | 07/23/2013
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Last Update Date | 08/08/2013
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Provider Practice Location Address
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Address Line | 8000 IH 10 W SUITE 600
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City | SAN ANTONIO
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State | TX
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Zip | 78230-3802
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Country | US
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Telephone | 210-417-5353
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Fax |
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Provider Business Mailing Address
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Address Line | 4836 WALTERS CIR UNIT A
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City | FORT SILL
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State | OK
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Zip | 73503-5010
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Country | US
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Telephone | 580-574-8414
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Fax |
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Authorized Official
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Title or Position | OWNER-PRESIDENT
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Name | MR. ERNEST H WALLACE
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Credential |
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Telephone | 757-503-2196
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332BC3200X
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Taxonomy Name | Customized Equipment (DME)
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 332BX2000X
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Taxonomy Name | Oxygen Equipment & Supplies (DME)
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 335E00000X
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Taxonomy Name | Prosthetic/Orthotic Supplier
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License Number |
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License Number State |
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