Provider Demographics
NPI:1073749495
Name:OPTIMAL SPINE & HEALTH MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:OPTIMAL SPINE & HEALTH MEDICAL CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:KEITH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:626-965-2334
Mailing Address - Street 1:2361 S AZUSA AVE
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91792-1537
Mailing Address - Country:US
Mailing Address - Phone:626-965-2334
Mailing Address - Fax:626-964-6504
Practice Address - Street 1:2361 S AZUSA AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91792-1537
Practice Address - Country:US
Practice Address - Phone:626-965-2334
Practice Address - Fax:626-964-6504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-01
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC15972111N00000X
CAC51512208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT18200Medicare UPIN
CA6348040001Medicare NSC
CACD916AMedicare PIN