=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467645077
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SALUD OPTIMA MEDICAL CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2007
-----------------------------------------------------
Last Update Date | 08/27/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1031 E LATHAM AVE STE 1
-----------------------------------------------------
City | HEMET
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92543-4425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-306-9888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1031 E LATHAM AVE STE 1
-----------------------------------------------------
City | HEMET
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92543-4425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-306-9888
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FOUNDER
-----------------------------------------------------
Name | MS. MARTHA IZVERNARI
-----------------------------------------------------
Credential | NURSE PRACTITIONER
-----------------------------------------------------
Telephone | 951-306-9888
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | G554810
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------