Provider Demographics
NPI:1295197630
Name:OPTIMED HEALTHCARE CLINIC LLC
Entity Type:Organization
Organization Name:OPTIMED HEALTHCARE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHACKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-205-2792
Mailing Address - Street 1:6321 SAN MARINO DR
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75089-4534
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6321 SAN MARINO DR
Practice Address - Street 2:
Practice Address - City:ROWLETT
Practice Address - State:TX
Practice Address - Zip Code:75089-4534
Practice Address - Country:US
Practice Address - Phone:214-205-2792
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-24
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty