MEDICARE: OPTIMA PHYSICAL THERAPY 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	2251X0800X	Orthopedic Physical Therapist	PT006105	GA

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

General Provider Information

NPI Number	:	1174593222
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTIMA PHYSICAL THERAPY INC

Provider Business Mailing Address
First Line	:	808 COMMERCE BLVD
Second Line	:	SUITE C2
City	:	RIVERDALE
State	:	GA
Zip	:	30296-7192
Country	:	US
Telephone Number	:	770-994-4335
Fax Number	:	770-994-1559

Provider Business Practice Location Address
First Line	:	808 COMMERCE BLVD
Second Line	:	SUITE C2
City	:	RIVERDALE
State	:	GA
Zip	:	30296-7192
Country	:	US
Telephone Number	:	770-994-4335
Fax Number	:	770-994-1559

Authorized Official
Title or Position	:	CLINIC DIRECTOR
Name	:	MR. GANIYU ABIOLA BELLO
Credential	:	PHYSICAL THERAPIST
Telephone Number	:	770-994-4335

Provider Enumeration Date	:	01/23/2006
Last Update Date	:	03/03/2014

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