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General NPI Number Information
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NPI Number | 1780232843
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Entity Type | Organization
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Legal Business Name | OPTIMUM VITALITY MEDICAL GROUP
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Dates
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Enumeration Date | 08/30/2019
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Last Update Date | 08/30/2019
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Provider Practice Location Address
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Address Line | 464 RICHMOND RD STE 202
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City | RICHMOND HEIGHTS
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State | OH
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Zip | 44143-2704
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Country | US
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Telephone | 330-824-4200
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Fax | 440-525-5564
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Provider Business Mailing Address
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Address Line | 464 RICHMOND RD STE 202
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City | RICHMOND HEIGHTS
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State | OH
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Zip | 44143-2704
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Country | US
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Telephone | 330-824-4200
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Fax | 440-525-5564
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Authorized Official
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Title or Position | BILLING CONSULTANT
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Name | KELLI BLACK
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Credential |
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Telephone | 216-750-3427
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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