Provider Demographics
NPI:1225468838
Name:OPTIMAL PERFORMANCE OCCUPATIONAL THERAPY, LLC
Entity Type:Organization
Organization Name:OPTIMAL PERFORMANCE OCCUPATIONAL THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VICKY
Authorized Official - Middle Name:
Authorized Official - Last Name:ENN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:863-232-5062
Mailing Address - Street 1:7606 N UNION BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-3850
Mailing Address - Country:US
Mailing Address - Phone:719-265-0088
Mailing Address - Fax:888-235-9876
Practice Address - Street 1:7606 N UNION BLVD
Practice Address - Street 2:STE A
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-3850
Practice Address - Country:US
Practice Address - Phone:719-265-0088
Practice Address - Fax:888-235-9876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-18
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COME2323225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO=========OtherBCBS