MEDICARE: OPTIMA THERAPY MN LCC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	252Y00000X	Early Intervention Provider Agency

General Provider Information

NPI Number	:	1073183018
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTIMA THERAPY MN LCC

Provider Business Mailing Address
First Line	:	2520 E HENNEPIN AVE UNIT D
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55413-2912
Country	:	US
Telephone Number	:	612-203-4555
Fax Number	:

Provider Business Practice Location Address
First Line	:	2520 E HENNEPIN AVE UNIT D
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55413-2912
Country	:	US
Telephone Number	:	612-203-4555
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	ABDISALAM OMAR MUSE
Credential	:
Telephone Number	:	612-203-4555

Provider Enumeration Date	:	07/01/2021
Last Update Date	:	07/02/2021

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