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General NPI Number Information
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NPI Number | 1295376119
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Entity Type | Organization
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Legal Business Name | OPTIMAL KIDS
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Dates
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Enumeration Date | 10/02/2019
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Last Update Date | 10/02/2019
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Provider Practice Location Address
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Address Line | 2506 S 115TH LN
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City | AVONDALE
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State | AZ
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Zip | 85323-7637
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Country | US
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Telephone | 623-628-7806
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Fax |
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Provider Business Mailing Address
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Address Line | 2506 S 115TH LN
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City | AVONDALE
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State | AZ
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Zip | 85323-7637
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OCCUPATIONAL THERAPIST
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Name | MARY SHOUSE
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Credential | MS, OTR/L
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Telephone | 623-628-7806
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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