Provider Demographics
NPI:1306363783
Name:OPTIMUM POTENTIAL COMMUNITY SERVICES LLC
Entity Type:Organization
Organization Name:OPTIMUM POTENTIAL COMMUNITY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LUCILLE
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:321-333-9197
Mailing Address - Street 1:120 BROADWAY STE 306
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-5706
Mailing Address - Country:US
Mailing Address - Phone:407-201-6577
Mailing Address - Fax:407-350-3425
Practice Address - Street 1:120 BROADWAY STE 306
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-5706
Practice Address - Country:US
Practice Address - Phone:407-201-6577
Practice Address - Fax:407-350-3425
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OPTIMUM POTENTIAL COMMUNITY SERVICES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty