=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891561999
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPTUM INFUSION CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2023
-----------------------------------------------------
Last Update Date | 01/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20414 N 27TH AVE STE 450
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85027-0002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-335-6786
-----------------------------------------------------
Fax | 844-855-0868
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15529 COLLEGE BLVD
-----------------------------------------------------
City | LENEXA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66219-1351
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-335-6786
-----------------------------------------------------
Fax | 844-855-0868
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF FINANCIAL OFFICER, MANAGER
-----------------------------------------------------
Name | JEFFREY DALLAGER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 952-205-7745
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QI0500X
-----------------------------------------------------
Taxonomy Name | Infusion Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------