Provider Demographics
NPI:1568461655
Name:OPTUMCARE MANAGEMENT, LLC
Entity Type:Organization
Organization Name:OPTUMCARE MANAGEMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:G
Authorized Official - Last Name:LIETHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-205-6262
Mailing Address - Street 1:3150 W PROSPECT RD
Mailing Address - Street 2:SUITE 320
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33309-2597
Mailing Address - Country:US
Mailing Address - Phone:954-677-1011
Mailing Address - Fax:954-677-0922
Practice Address - Street 1:3150 W PROSPECT RD
Practice Address - Street 2:SUITE 320
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33309-2597
Practice Address - Country:US
Practice Address - Phone:954-677-1011
Practice Address - Fax:954-677-0922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-20
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1312625332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1312625OtherHME LICENSE
5285090002Medicare ID - Type Unspecified