Provider Demographics
NPI:1407394851
Name:OPTUM HEALTH AND SPORT THERAPY
Entity Type:Organization
Organization Name:OPTUM HEALTH AND SPORT THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:GOVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-740-7908
Mailing Address - Street 1:201 TOWN CENTER LN
Mailing Address - Street 2:SUITE 1111
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-2158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 TOWN CENTER LN
Practice Address - Street 2:SUITE 1111
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-2158
Practice Address - Country:US
Practice Address - Phone:972-740-7908
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-06
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty