Provider Demographics
NPI:1508197799
Name:EXTENDED OPTIMUM MEDICAL SERVICES LLC
Entity Type:Organization
Organization Name:EXTENDED OPTIMUM MEDICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:TAWANA
Authorized Official - Middle Name:LAE
Authorized Official - Last Name:GRACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:908-644-2650
Mailing Address - Street 1:30 WORLDS FAIR DR
Mailing Address - Street 2:SUITE110
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-1346
Mailing Address - Country:US
Mailing Address - Phone:908-644-2650
Mailing Address - Fax:
Practice Address - Street 1:1130 ROUTE 202
Practice Address - Street 2:SUITE #6 BLDG E
Practice Address - City:RARITAN
Practice Address - State:NJ
Practice Address - Zip Code:08869-1490
Practice Address - Country:US
Practice Address - Phone:908-644-2650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-27
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health