=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679782601
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPTIMUM PHYSICAL THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2007
-----------------------------------------------------
Last Update Date | 11/28/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13906 GOLD CIR SUITE 103
-----------------------------------------------------
City | OMAHA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68144-2335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-639-6708
-----------------------------------------------------
Fax | 402-614-4730
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 45502
-----------------------------------------------------
City | OMAHA
-----------------------------------------------------
State | NE
-----------------------------------------------------
Zip | 68145-0502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 402-639-6708
-----------------------------------------------------
Fax | 402-614-4730
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, THERAPIST
-----------------------------------------------------
Name | MRS. CASANDRA MARIE BAKER
-----------------------------------------------------
Credential | P.T., O.C.S.
-----------------------------------------------------
Telephone | 402-639-6708
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Clinic/Center
-----------------------------------------------------
License Number | 600
-----------------------------------------------------
License Number State | NE
-----------------------------------------------------