Provider Demographics
NPI:1548229610
Name:OPTIMUM MEDICAL SUPPLY, INC
Entity Type:Organization
Organization Name:OPTIMUM MEDICAL SUPPLY, INC
Other - Org Name:OPTIMUM MEDICAL SUPPLY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:ADE
Authorized Official - Last Name:OJO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-796-7772
Mailing Address - Street 1:2797 S MARYLAND PKWY STE 13
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89109-1576
Mailing Address - Country:US
Mailing Address - Phone:702-796-7772
Mailing Address - Fax:702-796-7773
Practice Address - Street 1:2797 S MARYLAND PKWY STE 13
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89109-1576
Practice Address - Country:US
Practice Address - Phone:702-796-7772
Practice Address - Fax:702-796-7773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-18
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100500013Medicaid