=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598891848
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPTILIFE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2007
-----------------------------------------------------
Last Update Date | 01/13/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1400 QUAIL ST SUITE 150
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92660-2730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-520-9759
-----------------------------------------------------
Fax | 949-442-1664
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1400 QUAIL ST SUITE 150
-----------------------------------------------------
City | NEWPORT BEACH
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92660-2730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-520-9759
-----------------------------------------------------
Fax | 949-442-1664
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. GEOFFREY A.W. DIBELLA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 714-520-9759
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | G21681
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------