Provider Demographics
NPI:1245804525
Name:OPTIMA VITAE, LLC
Entity Type:Organization
Organization Name:OPTIMA VITAE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:979-431-4848
Mailing Address - Street 1:3201 UNIVERSITY DR E STE 160
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-3480
Mailing Address - Country:US
Mailing Address - Phone:979-431-4848
Mailing Address - Fax:979-431-4846
Practice Address - Street 1:3201 UNIVERSITY DR E STE 160
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-3480
Practice Address - Country:US
Practice Address - Phone:210-305-9057
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-19
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE