=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700567906
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPTIMAL MIND PSYCHIATRY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2023
-----------------------------------------------------
Last Update Date | 07/31/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1505 PENNSYLVANIA AVE
-----------------------------------------------------
City | MCDONOUGH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30253-9114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-218-8934
-----------------------------------------------------
Fax | 678-603-2086
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1705 WILLIAMSON RD STE 101
-----------------------------------------------------
City | GRIFFIN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30224-5471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-218-8934
-----------------------------------------------------
Fax | 678-603-2086
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. ONYEBUCHI NWAOKOLO
-----------------------------------------------------
Credential | DNP
-----------------------------------------------------
Telephone | 404-218-8934
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------