=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447640602
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPTIMUS HEALTHCARE AGENCY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2015
-----------------------------------------------------
Last Update Date | 01/27/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 228 MORROW RD APT 25C 1230 PEACHTREE ST SUITE 1900 ATLANT GA 30309
-----------------------------------------------------
City | FOREST PARK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30297-2822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-437-0983
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 228 MORROW RD APT 25C
-----------------------------------------------------
City | FOREST PARK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30297-2822
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-437-0983
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CNA
-----------------------------------------------------
Name | JACQUELINE WHITE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-437-0983
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------