MEDICARE: OPTIMUM RESIDENTIAL SERVICES LTD

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	310500000X	Mental Illness Intermediate Care Facility	007231	TX

General Provider Information

NPI Number	:	1831155274
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTIMUM RESIDENTIAL SERVICES LTD

Provider Business Mailing Address
First Line	:	845 PROTON RD
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78258-4203
Country	:	US
Telephone Number	:	210-340-7155
Fax Number	:

Provider Business Practice Location Address
First Line	:	2579 WESTERN TRAILS BLVD
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78745-1578
Country	:	US
Telephone Number	:	512-892-2191
Fax Number	:	512-892-2524

Authorized Official
Title or Position	:	CFO
Name	:	MR. MIKE HAWKER
Credential	:
Telephone Number	:	210-340-7155

Provider Enumeration Date	:	04/25/2006
Last Update Date	:	08/22/2020

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Directions to “OPTIMUM RESIDENTIAL SERVICES LTD ” Practice Location

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