MEDICARE: OPTIMUM BEHAVIORAL CARE LLC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1679080584
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTIMUM BEHAVIORAL CARE LLC

Provider Business Mailing Address
First Line	:	P O BOX 370488
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89137
Country	:	US
Telephone Number	:	702-210-9896
Fax Number	:

Provider Business Practice Location Address
First Line	:	2797 S MARYLAND PKWY STE 13
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89109-1576
Country	:	US
Telephone Number	:	702-210-9896
Fax Number	:

Authorized Official
Title or Position	:	MANAGING PARTNER
Name	:	PHILIP ADE OJO
Credential	:
Telephone Number	:	702-210-9896

Provider Enumeration Date	:	01/02/2018
Last Update Date	:	01/02/2018

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