Provider Demographics
NPI:1144609876
Name:OPTIMUS DIAGNOSTICS LLC
Entity Type:Organization
Organization Name:OPTIMUS DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:478-621-2100
Mailing Address - Street 1:1005 BOULDER DR
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:GA
Mailing Address - Zip Code:31032-6141
Mailing Address - Country:US
Mailing Address - Phone:478-621-2100
Mailing Address - Fax:478-744-0481
Practice Address - Street 1:252 HOLT AVE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-1227
Practice Address - Country:US
Practice Address - Phone:844-832-5414
Practice Address - Fax:877-455-7176
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLINICAL SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-05-27
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
202G633154Medicare PIN