=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396144481
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPTIMAL T CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2014
-----------------------------------------------------
Last Update Date | 12/14/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21820 KINGSLAND BLVD STE 101
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77450-2508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-321-5402
-----------------------------------------------------
Fax | 832-321-5407
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21820 KINGSLAND BLVD STE 101
-----------------------------------------------------
City | KATY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77450-2508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-321-5402
-----------------------------------------------------
Fax | 832-321-5407
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | LORI STEPHENS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 832-321-5402
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | AP122302
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------