MEDICARE: OPTIMUM AGING & INTEGRATED MEDICINE

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	207Q00000X	Family Medicine Physician	2789	OK
2	207Q00000X	Family Medicine Physician	E-2638	AR

General Provider Information

NPI Number	:	1508103029
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTIMUM AGING & INTEGRATED MEDICINE

Provider Business Mailing Address
First Line	:	PO BOX 7132
Second Line	:
City	:	VAN BUREN
State	:	AR
Zip	:	72956-0124
Country	:	US
Telephone Number	:	479-784-0011
Fax Number	:	479-784-0012

Provider Business Practice Location Address
First Line	:	2641 ROGERS AVE
Second Line	:
City	:	FORT SMITH
State	:	AR
Zip	:	72901-4145
Country	:	US
Telephone Number	:	479-784-0011
Fax Number	:	479-784-0012

Authorized Official
Title or Position	:	OWNER
Name	:	TERRY L HOYT
Credential	:	D.O
Telephone Number	:	479-784-0011

Provider Enumeration Date	:	01/04/2013
Last Update Date	:	05/14/2013

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