Provider Demographics
NPI:1063854743
Name:OPTIMUM FOOT CARE
Entity Type:Organization
Organization Name:OPTIMUM FOOT CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:H
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-503-2196
Mailing Address - Street 1:4836 WALTERS CIR
Mailing Address - Street 2:UNIT A
Mailing Address - City:FORT SILL
Mailing Address - State:OK
Mailing Address - Zip Code:73503-5010
Mailing Address - Country:US
Mailing Address - Phone:580-574-8414
Mailing Address - Fax:
Practice Address - Street 1:8000 IH 10 W
Practice Address - Street 2:SUITE 600
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-3802
Practice Address - Country:US
Practice Address - Phone:210-417-5353
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-23
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies