Provider Demographics
NPI:1245564012
Name:OPTUM INFUSION SERVICES 302, LLC
Entity Type:Organization
Organization Name:OPTUM INFUSION SERVICES 302, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:BURR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-310-4701
Mailing Address - Street 1:11000 OPTUM CIR STE 100
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-2503
Mailing Address - Country:US
Mailing Address - Phone:800-328-5979
Mailing Address - Fax:
Practice Address - Street 1:8720 SOUTH 114TH STREET, SUITE 106
Practice Address - Street 2:
Practice Address - City:LA VISTA
Practice Address - State:NE
Practice Address - Zip Code:68128
Practice Address - Country:US
Practice Address - Phone:855-295-3154
Practice Address - Fax:844-204-8056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-28
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336H0001XSuppliersPharmacyHome Infusion Therapy Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025826900Medicaid
2817863OtherNCPDP PROVIDER IDENTIFICATION NUMBER
NE10025826900Medicaid
6355320001Medicare NSC