Provider Demographics
NPI:1518953959
Name:OPTIMAL PERFORMANCE PHYSICAL THERAPY,LLC
Entity Type:Organization
Organization Name:OPTIMAL PERFORMANCE PHYSICAL THERAPY,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:PT, ATC/L
Authorized Official - Phone:207-510-6500
Mailing Address - Street 1:308 US ROUTE 1
Mailing Address - Street 2:SUITE E1
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9774
Mailing Address - Country:US
Mailing Address - Phone:207-510-6500
Mailing Address - Fax:207-510-6565
Practice Address - Street 1:308 US ROUTE 1
Practice Address - Street 2:SUITE E1
Practice Address - City:SCARBOROUGH
Practice Address - State:ME
Practice Address - Zip Code:04074-9774
Practice Address - Country:US
Practice Address - Phone:207-510-6500
Practice Address - Fax:207-510-6565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-21
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME355381700OtherWORKERS COMPENSATION
2116674OtherCIGNA
3623516OtherAETNA
=========OtherANTHEM
OP-ME1589Medicare ID - Type Unspecified