MEDICARE: OPTIMAE LIFESERVICES, INC,

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	1041C0700X	Clinical Social Worker	03816	IA
2	251S00000X	Community/Behavioral Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	58181	OTHER	IA	BCBS

General Provider Information

NPI Number	:	1174520084
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTIMAE LIFESERVICES, INC,

Provider Business Mailing Address
First Line	:	301 W BURLINGTON AVE
Second Line	:
City	:	FAIRFIELD
State	:	IA
Zip	:	52556-3242
Country	:	US
Telephone Number	:	641-472-1684
Fax Number	:	641-472-4609

Provider Business Practice Location Address
First Line	:	301 W BURLINGTON AVE
Second Line	:
City	:	FAIRFIELD
State	:	IA
Zip	:	52556-3242
Country	:	US
Telephone Number	:	641-472-5771
Fax Number	:	641-472-1817

Authorized Official
Title or Position	:	DIRECTOR OF BILLING
Name	:	MS. NANCY LYNN MCSTOCKARD
Credential	:
Telephone Number	:	641-472-1684

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	07/29/2013

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