Provider Demographics
NPI:1508015389
Name:OPTIMUM SPINE AND HEALTH CLINICS, P.C.
Entity Type:Organization
Organization Name:OPTIMUM SPINE AND HEALTH CLINICS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-974-5555
Mailing Address - Street 1:4091 S REDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84123-1131
Mailing Address - Country:US
Mailing Address - Phone:801-974-5555
Mailing Address - Fax:801-974-1903
Practice Address - Street 1:4091 S REDWOOD RD
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84123-1131
Practice Address - Country:US
Practice Address - Phone:801-974-5555
Practice Address - Fax:801-974-1903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-16
Last Update Date:2008-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2789521202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty