MEDICARE: OPTIMUM SPINE CENTER, 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	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1922510643
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTIMUM SPINE CENTER, LLC

Provider Business Mailing Address
First Line	:	5555 PEACHTREE DUNWOODY RD STE G99
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30342-1700
Country	:	US
Telephone Number	:	678-539-6575
Fax Number	:	404-574-5944

Provider Business Practice Location Address
First Line	:	5555 PEACHTREE DUNWOODY RD
Second Line	:	SUITE G99
City	:	ATLANTA
State	:	GA
Zip	:	30342-3034
Country	:	US
Telephone Number	:	678-539-6575
Fax Number	:	404-574-5944

Authorized Official
Title or Position	:	OFFICER / AUTHORIZED OFFICIAL
Name	:	COLLIN LEMAISTRE
Credential	:
Telephone Number	:	469-250-3640

Provider Enumeration Date	:	11/03/2017
Last Update Date	:	09/13/2024

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